HomeMy WebLinkAbout0081 RALYN ROAD - Health 81. Ralyri Road
cotuit
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LO CATION _ S WAGE PERMIT N0.
VILLAGE
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d �
INSTA LLER'S NAME & ADDRESS
.Sete .
�•BUtLDER OR OWNER
'DATE PERMIT ISS-'U E D
—
DATE COMPLIANCE ISSUED
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No......... _.._ _ -
THE COMMONWEALTH OF-MASSACHUSETTS
--77--- BOAR® O `nn� HEALTH
..........L.QCl.1► l....-._.....OF.....� 0.Z.mb).�...........................
Aptira#iou for %gpvia1 Works Tonfitrurtiun rami#
Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal
System at: •
�u� n L Yl l boa d C��7vi>�
Q . 1/ J -----------�--,-�----•-------------------Vata
i or No.
v
Installer J Address
Q Type of Wilding ( Size Lot............................Sq. feet
Dwelling—N gfp Bed
jo ms______________'_-________.__.___._.__.__._.__Expansion Attic ( ) Garbage Grinder ( )
Other—Typ�of f3oi ff g .......QV................. No. of persons........ .......... Showers (Q) — Cafeteria ( )
a Other fixtures _________________________________ _
W Design Flow--------------------------------------------gallons per person per flay. Total daily//flow____._._._.__q.1��_________________gall?ns.
WSeptic Tank—Liquid capacity�Qa_gallons Length__I!Q__ir?__ Width_.�1.__�P... Diameter________________ Depth__.-5........
Disposal Trench—N __._._.____ Width ___ Total Length________________ Total leaching area....................Sq. ft.
p _•
Seepage Pit No._._____!.._______. iameter... ..X_�a_._._. Depth below inlet__._.... __ Total leaching area_., _�st.
Other Distribution box (� Dosin -t nk ( ) �^''A ye- A-��'
z Percolation Test Results Performed by-__ a r.1 c_ _.__:S_. h __ Date_./.!!/Q_ �__a_�___�9...
a minutes per inch Depth of Test �----)�_ ___ Depth to ground water.-CID__. !"t?U!?C�Cneouniered
Test Pit No. 1___._�2 �^
(i, Test Pit No. 2____._`_'�_.____.minutes per inch Depth of Test Pit_____�a._-!-.* Depth to ground watern_._��rGUn-o�n cai)n
Cc�unreiT)
R•i --••--•-•--- ........................
- ---••_________________•---•-------------------
--------•--------
O Description of Soil-- ....-Q-U Y�:---- 11_ D� �SC._ ���_w-n----��G�n�1. -- --- -- -
U ..--•-----•--------------•-------------......------------•----•-------...-----------------......------•---------------------------------•--------------...-•-----------.......--•-------•----••-•-------
W --------•------------------•-----•--------------------------------------------------------------•----------------------------.....---------------------------------------••----•••--•-------------••-
UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
Agreement:
_ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIa� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ed by the bo th.
Si n ... 'L 6 _ ._.
g - � - --••••
• �`te�
Application Approved By....... . // '�`" -------------••-- -------`
Date
Application Disapproved for the following reasons:-------•----•-•------- •-•---•--•-----••---------•---------•----•=-•••-•--••-•----•-••---•--•------...---•----
----------------------•..._•----•---•--------•-•---••----••-....-•--•-••------•••-•---------••-•---•-•....-•••••-•-••--•-----••-•--••-----..............................................................
Date
PermitNo......................................................... Issued----L__-_.L..............................
` Date
No........................ Finc.............................
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD' OF HEALTH
...........I----- - n..............OF.... .........................................................................
Appfiration for Disposal lVorkp Tomitrurtion rumit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
S stem at:
e-1 I * ...t- ......eahln.....a.a...d.,..Cc)Tol
7 rul Cco Ecq 2�a.tc\_)
or Lot No
11, Ss5
............
. ...................................................................... .. ........ ........
ldl,,s
To-(OTl_r C a ....... .... ...
W.fl�................................................................
Installer 7'
Address
'�ilding Size Lot............................Sq. feet
Type of B
U
Dwelling— o. Gf.Bed ms............. _Expansion Attic Garbage-Grinder (
�4 P
Other—Type or�ijuilditi * T1 o U sons........ ------------ Showers Cafeteria (
PL4 / g ............... .......... No. of per
Otherfixtures ......................................................................................................................................................
DVsign- Flow............................................gallons pEr person per day. Total daily, flow--- J ..V j/)0..................gallons.
7
Ra
Septic Tank—Liquid capacity�J_0.0..gallons Length./ n--- Width__
.-to -I---- Diameter................ Depth-.; ..j......
)-'
Disposal Trench—No.................... Width.........:�........�Total Length..................... Total leaching area....................
Seepage Pit No..._..../------- iameter._6._K,6_,`�.... DepJ!,�obelow inlet... 02ta��ac ---OVt.
.. A 4V
z Other Distribution box ✓ Dosin tank ti
Percolati6n Test Results Performed b4 Date..NO V
Eba.uc ._, -------------------* ..................................
Test Pit No. I -___.minutes minutes per inch -1 Depth of Test Pit It Depth to ground water..0Q__QT,/1,1(! C-Je-0L,,j'C1'rd
<
Test Pit No. 2................minutes per inc h of Test Pit..... Depth to ground L
1:1, � -
----------*
..........................................................................................................F........................
-()r -o 0 Description.of Soil........( f � -�7e t�(
...... ...................................b1c)-----i�_) _ad.....................................
U ...................................................................................;.............................................................................................w.....................
...................................................................................�1:....................................................... ...........................................................
U Nature of Repairs or Alterations—Answer w -----------------------------------------------...............................................
when applicable
7............................................................................................................................................................:---------------------------------------
'Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT E .5 of the State Sanitary'Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beb.n ' ,ued by the bo ,- of-hea-Ith.
All
--I _/,;�X
ign . . .............................:...... ..................................... ......
7
A ........................................
pplication Approved By........ ....... ... .............. .... .....Z ...........
Date
Application Disapproved for the following reasons ....................../..................................................................................
............................................................................................I.......... ..............................................................................
Date
PermitNo........................................................ IssuedL.............................................4*:: ......
Date
THE.ZOMMONWEALTH OF MASSACHUSETTS
;BOARD OF HEALTH �
......... io
.w ......................
THIS IS TO CERTIFY, That the Individual Sewage Disposal'System constructed �6r Repaired
0
b
3-r."t 1-1 j .. - -.1- . -
y----------------------.. .............. .. ...... ................................................................................
7j- ......I.................. .........................................
at ........ -------
has been installed in accordance with the provisions of T of TJieState Sanitary Cc4e..�s-described in the
7- -7/Q'
application for Disposal Works Construction Permit No_____U /......... dated_....----_....._.........._..._._................-.
THE 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
A.i .............OF�...........Rrt...........)..C..C,
....................
No......................... ...........
Disposal Works Tonotrurtion lirrmit
Permission is hereby granted.......C ig ......f��-t ......
K:;j� 74 _/ , .1ULV.0....; . .77---—0- —1—.........�,.............................................
to Construct /0 r Repair an Individdal Sewage Disposal System
...... ............................................
at No. ...... .......
0 7" uc)"J ) � Street 1 3-7-7'91
as shown on the application for Disposal Works.Construction Nr �Per gio. ated..........................................
f'
-------------------
oajd of Health
DATE...........7..... 7,7-.......................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHER S
Commonwealth of Massachusetts
o 0101 - o(p a
�. ;to Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit ✓ MA 02635 5/7/21
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information 614t ISLI a$
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: 1 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
5/7/21
Inspecto nature 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 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
i? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved-by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. City(rown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The-
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. Cityrrown 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.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
re Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy Is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
n
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat,.or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out? ,
® ❑ Were all system components, excluding the SAS, located on site?
❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
4 bedroom permit and plan on file at BOH
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection- ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 193 GPD
9 ( Y 9 (gp ))�
Detail.-
Sump pump? ❑ Yes ® No
Last date of occupancy: April 2021
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�n r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
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(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: No recent pumping per owner
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
lip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t; 81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1979 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every COtuit MA 02635 5/7/21
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
18,
Depth below grade: feet
Material of construction:
® concrete I ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, inlet cover raised to 2" of grade
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach'a copy of certificate) ❑ Yes ❑ No
Dimensions: 15oog
9„
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle '12
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u, 81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
I� 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
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-10 D-box is 2'6" below grade, poly cover to 10" of grade, no adverse conditions observed
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
I
Commonwealth of Massachusetts
�. ,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
s re Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•u, 81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. Cityrrown 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.):
Leach pit is 3' below grade, steel cover to grade, 6" of effluent in pit at this time, stain line 2' below the
invert, no indication of past hydraulic failure
I
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I .
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
n 81 Ralyn Rd.
Property Address
Marks
Owner Owners Name
information is
required for every Cotuit MA 02635 5/7/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L 81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every . COtUit MA 02635 5/7/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: >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: 1979 NGW 144"
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
4' seperation per compliance on file at BOH
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping puts the site at 58'msl and nearby surface water at 12'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u 81 Ralyn Rd.
Property Address
Marks
Owner Owner's Name
information is
required for every Cotuit MA 02635 5/7/21
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
i ® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
..�� 81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
�I I
forms on the !( ]�
computer,use 1. Inspector:
only the tab key
to move your P. Scott Campbell
cursor-do not Name of Inspector
use the return
key. Cardinal Construction
Company Name
32 Ridgetop Rd.
Company Address
Cotuit Ma 02635
City/Town State Zip Code
508-420-1295 S1388
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
co information reported below is true, accurate and complete as of the time of the inspection.The inspection
c� was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
IL t
m,Passes ❑ Conditionally Passes ❑ Fails
CO
C) ®J;Needs Further Evaluation by the Local Approving Authority
11/3/2010
Inspector's ignature Ap, 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 applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
V
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 1 of 17
Commonwealth of Massachusetts
ugTitle 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments,81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
Installed riser on d-box
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair;as approved by
the Board of Health,will pass.
Check the box for"yes"., "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner owners Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution.box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping,more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
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:
Ej 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. City/Town State Zip Code Date of InsPection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and.the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent.and.the presence of ammonia nitrogen.and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day.flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. City/Town 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
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 well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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.
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 watersupply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
11 ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 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.
t5ins•09/08 Title 5 official Inspectio Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner Owners Name
information is required for Cotuit Ma 02635 11/3/2010
every page.. Cityrrown 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
® ❑ Pumping information was.provided by the owner,.occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
;dimensions, depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location.of the Soil Absorption System.(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is atissue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
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
r
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page: Cityrrown State. Zip Code Date of inspection
D. System Information.
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No.
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2010 48,000 2009 43,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current 2010
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste.holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Pump truck measureing sight glass.
Reason for pumping: Maintenance pumping. Pumping done after inspection
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):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. CityrTown State: Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Compliance date 4/11/1979 board of health records on file
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments.(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
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:
Sludge depth:
t5ins•091W Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'y 81 Ralyn Rd.
Property Address
David Wells
Owner Owners Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Cityfrown State Zip Code Date of Inspection
!D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 0
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? Visual
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
.System m u ed after inspection was complete
pumped P P
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
f
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•09/08 Title 5 Official Ins
pection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 81 Ralyn Rd.
Property Address
David Wells
Owner Owners Name
information is required for Cotuit Ma 02635 11/3/2010
every page. City/rown State Zip Code: Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
System needed to be pumped after inspection was complete. Inlet and outlet tee and baffle in place
at time of inspection. system working properly at time of inspection, no evidence of leakage.
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Cityrrown State. Zip Code. Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is level small amount of solids carryover to box. No evidence of leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
1000 gallon leach pit with 3'.F water in pit at time of inspection.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
.David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Cityrrown State Zip Code Date.of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Dry soil, no signs of hydraulic failure, no ponding or damp soil, normal vegetation. (grass)
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-0g/08 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
TitleOfficial ' -
5 o cia Inspection Form
u
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ratyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Cityyfrown State Zip Code Date of Inspection
D. System Information (cost.)
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 welts within 100 feet Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
El drawing attached separately
AVD4 i 0
20 ,
t5ins-09108 Idle 5 Official insp
ection Form:Subsurrace Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner Owners Name
information is required for Cotuit Ma 02635 11/3/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12+feetfeet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Inspection at time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Ralyn Rd.
Property Address
David Wells
Owner Owner's Name
information is required for Cotuit Ma 02635 11/3/2010
every page. Cityrrown State. Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary_D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 17 of 17
F. F. 5 ono, � TYPICAL SYSTEM PROFILE
AREA PLAN :. FINISH GRADE= 51,.0
FDN TOP ' - NOT TO SCALE
` p 1061 I FINISH _50.C14 /
SCALE : I - L FINISH GRADE OVER TANK= {® GRADE OVER PIT-__
LOT 24 RAL YN ROAD 2 1 , 8 34 +
.�. , .. . ..��...... u
n ° ®PVC OR O O� OT N THE AA STA I � FLOOD PLAIKIL -97.G-7C. I. TEES o BSMT . • ;, •• .•• ••-"'•-:•o
500
:..m.•- a:, v • e o • • e • e e
GAL. 4 �•-r/ ,�-� e • o o • • • o � o �
�. �..�_ .. REINFORCED DIST. BOX • o o • • • e e e o ,
CONCRETE $ I TO BE INSTALLED ON / 1 ' / • • ® + • o 0 0
A LEVEL STABLE BASE ► / o . • o o • o 0
SEPTIC TANK
LO � 18 LOT 17 c, • o o a . • • • a e o 1 l
� '1"�F @. TO BE INSTALLED ON A e • • e e -• • e o
5,F MD.TOP@,,39,40 1,P, FND, TOP M 45,60 � 4$.•2C�' LEVEL STABLE BASE r.
/ e • • • , • • 0 1 0
.-._ �.. .�. 2�,_1/8,� 1/2 „WASHED PEASTONE ALL Y e e • • • • w • • • • • s'
BRICK a .MORTAR COURSES AS
AROUND FREE OF IRONS, FINES e " • e • • o e o a y
' LOT 2 Ij REQUIRED TO BRING COVER TO GRADE AND DUST IN PLACE
1� 24 "C.I . MANHOLE COVER a 3/4 "TO 1-I 2 "WASHED CRUSHED LEACHING PIT
2- 1 ,8 3 , "' 1 sore I T, P co�Iccz
AREA, FOR1'F+NK-�l5t:P_ Pr ?OV-4LE FRAME - SEE DETAIL STONE ALL AROUND FREE OF BASE TO BE LEVEL
LOT 2 3 PI I +Ac3.9g� PLACEIRONS, FINES AND DUST IN
T.H, LOTS 2 ( I
FOR FIN. GRADE
P2E;GA � _GD4CiT SEE SYSTEM PROFILE
r LEAC1-I I M q PIT— ) RFQ Q � SOIL AND PERCOLATION
40 t- SEE D5TAI1-
luu«Ir i,
PP—QfYIILE 4„ �I 111�- —:
DATA
51 PERC. RATE MIN./IN,
,t7f� / 4" FOR INV. ELEV SEE
INLET - ,° ° SYSTEM PROFILE o , 6'� TAKEN BY : C. D. SPOHR
I 00 LINE D .U� rnucz�aY 6AQ►aSreeLe sD.o+" H .aT}t
2A i PFr�oio _ WITNESSED BY.
A B Di Atyltib ° o D OPENINGS W/4-1�8 ��0 28 OCT. 2
0 OUTER DIA. a I -3 4 a ,` DATE:
-- -,E ., ►a' H4US� ,_0 t � 7 ,- ' ° INSIDE DIA . o = TEST PIT- 'lIcl%S
_ LE
1 (5tim-) za t FULL. MSh+-r,t slDh) 16 _ D TOTAL o D
o GND E V. `I' �i
C o '
5O3REA+50,� Np RUST, LEDr sue OP_ WATIF
Pam. • . ° o 0 0 0 0
_ o
o
E
A,TL- o o -
• a o � u � 0 r ,
,
13 �Fft14T) LINE 1 I s `
1, f? Fh.1D• '
roles• 55,9 s ,_ 6 �, o I A . �,._ 3 SAN D
(c.B,FcD.roP -- � .�.-- I�it , gs ) ,' st EFFECTIVE D I A. BOT. PERC. HOLE
qGt LL t+s5uuFp El-F-v +Zo e>o ;� R_��, � I P. �t�D.
``� — { LEACHING PIT SECTION DOWN 4 II
TOP 5Q. tt
p
C 4
L
of hx Yt No SCALE DESIGN
DATA-. .• �
r
(� NOTE: DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM No. of BEDROOMS
P —,,...,,,
l
LEACHING PIT NOTES: DlsPosAL
EST. TOTAL DAILY EFFLUENT 44 0 GALS.
�w I . CONC. TO BE 4000 P.S.I a 28 DAYS . SEPTIC TANK I
2. REINE W 6 " x 6 " 06 GA. W. W. M.
3. 2 `AND 4 ' SECTIONS ARE AVAILABLE FOR
_-
GREATER DEPTH REQUIREMENTS GENERAL NOTES—
OWNER •, I , ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
`-- -- NOTE: g0'02 ACCORDANCE WITH TITLE OF THE STATE SANITARY CODE
EXCAVATE TO ELEV. OR LOWER AS DATED JULY 171977 aANY LOCAL RULES APPLICABLE.
• � � ��'. �+� ��� � �� `—'• M. NOTE: REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING
MATERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL 2. ANY CHANGE TO THIS PLAN MUST BE APPRD. BY THE
(og OLa I�E�T 1NQ HOL D, ALL ELEVS, 5A5ED ON, -OP 017 EXIST. WITH MATERIAL
BENEATH
FREE GRAVEL, MECHANICALLY BD. OF HEALTH, AND CHARLES D. SPOHR.
ER�J `�'"' U1f't '" 3. WHEN CONSTRUCTION IS COMPLETED PRIOR TO BACKFILLING
Tk•L R 5 �S -- 0 14 � C, t�, Aga �#-iC� �ffi� ON a'i'l�ET� �? L , COMPACTED IN PLACE. ,
. ASS>L)WED +-E50.00 SIDE AREA = 3C S.F. S.F./GAL .? Z _.GALS
NOTIFY THE ENGINEER FOR INSPECTION.
BOTTOM AREA= I-2-1� S.F S. F./GAL 1 0 2. GALS 4, FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED.
. I �-
TOTAL AREA = 359 S. F. TOTAL 5'74 : GALS 5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT WRITTEN
APPROVAL BY CHARLES D. SPOHR,
LEGEND 6.-FOUNDATION INSPECTION READ. WHEN EXCAVATED.
AREA PLAN: + 50.0` EXIST. GROUND ELEV.
50.0` FINISH GROUND ELEV."UNDERLINED"
J-AKITU 'T./'C6TUr'T COUN • Y ESrAT I• t=01 4750] PIPE INVERT. ELEV. REV. DATE DESCRIPTION
t 1 �'-� lr '• • t p
P-A``(�stONJU D. � 1''0L.YW VAC, C�'A �v PAD
46
1 -4 Pit 40Y, 19 GS
TEST PIT LOCATION SEWAGE DI SPOSAL. SYSTEM
) o o SEPTIC TANK FOR
DISTRIBUTION S T R I B U T I O N BOX
MR,4 MRS, GARY S. TAVARES
® ^ �....----.�,,.,`
y LOT
—*- 24 RALYN ROAD ,
4 " C. I . PIPE . �,. J= .�
"-11-ti-H-t-t-}- 4"BIT. FIBER PIPE -TIGHT JOINTS . r �
COTU i Ts, MASS.
— PROPERTY LINE j DESIGNED: C.D.SPOHR DATE:l'F `7 DRAWING N0.
DRAWN: C-51 SCALE:AS SHOWN
�_ MIN. CODE DISTANCE .. _ .,-
MA,P SEC PCL LOT CHECKED: C. D.' S .
_ f