HomeMy WebLinkAbout1478 SANTUIT-NEWTOWN ROAD - Health 1478 SANTUTT-NEWTOWN I COTUIT
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LOCATION SEWAGE #
VILLAGE „� �,� ASSESSOR'S MAP & LOT 0�2- -1017
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SEPTIC TANK CAPACITY t(��O GG�L t
LEACHING FACILITY:(type) IX, kw3.x& (size)
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER
BUILDER OR OWNER Vk`
DATE PERMIT ISSUED: 0
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DATE COMPLIANCEISSUED:
VARIANCE GRANTED: Yes No �/
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , CP?
{
1478 Santuit Newtown Road F
Property Address
Cara& Paul Meneses r_A
Owner Owner's Name h
information is COW / MA 02635 February 11, 2021
required for every I
page. Cityrrown 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 A. Inspector Information
filling out forms
on the computer,use.only the tab Patrick T. Sullivan F
:
_ key to move your• Name of Inspector
cursor-do not Ready Rooter Excavating
use•the return Company Name
key. PO Box 89
d' al Company Address
Forestdale MA 02644
Cityrrown State Zip Code
508-888-6055 S112843
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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. 8 Conditionally Passes
3. 8 Needs Further Evaluation by the Local Approving Authority
4. F1 Fails ,
��- February 16, 2021
Inspecto 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
' t
Y
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses {
Owner Owner's Name
information is required for every Cotuit MA ' 02635 February 11, 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:
2) System Conditionally Passes:, t +
❑ 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 Id*or the septic tank(whether metal or not) is structurally
"unsound, exhibits substantial infiltration o iltration or tank failure is imminent. System will pass
inspection if the existing tank is replace with a complying septic tank as approved by the Board of
Health.
*A metal.septic tank will pass inspe ion if it is structurally sound,4 not leaking and if a Certificate of
Compliance indicating that the tank s less than 20 years old is available.
• a ,
❑ Y ❑ N. ❑ D (Explain below):
t5insp.doc•rev.7/26/2018 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts.
Title 5 Official Inspection Form .
h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara & Paul Meneses
Owner Owners Name
information is required for every Cotuit MA 02635 .february 11, 2021
page. Cityfrown 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 s/rem6ved
u or break out or high static water level in the distribution box due
to broken or obst )or due to a broken, settled or uneven distribution box. System will
pass inspection ival of Board of Health):
❑ broken pipe(s) placed ❑ :Y' ❑ N ❑ ND(Explain below):
❑ obstructied - ❑ Y ❑ N ❑ ND(Explain below):
•distrlbutiveled or replaced ❑ Y ❑ N ❑ ND,(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipeI(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced )r' ❑ Y ❑ N ❑ ND (Explain below):
❑ ,�, 'obstruction,is removed X ❑ Y ❑ N ❑ ND(Explain below):
r-
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 is1ailing 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: r
3`
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara & Paul Meneses
Owner Owner's Name '
information is Cotuit MA 02635 February 11, 2021
required for every
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 it absorption system (SAS)and the SAS is within
100 feet of a surface water supply or ibutary to a surface water supply.
❑ The system has a septic tank a d'!SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tan and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic t nk and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water s ply well**.
Method used to determine (stance:
**This system passes if the ell water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates bsent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, pro ided 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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
E ® 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses
Owner Owner's Name
information is required for every Cotuit MA 02635 February 11, 2021
page. Cityrrown 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
El ® 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.
El ® 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.
❑ N ' 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 w' hin 400 feet of a surface drinking water supply
❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply
El ❑ the system s located in a nitrogen.sensitive area(Interim Wellhead Protection
Area—I A)or a mapped Zone li of a public water supply well
t5insp.doc-rev.7126/2018 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
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses
Owner Owner's Name
information is Cotuit MA 02635- -'February 11,2021 .
required for every
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: d"
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
El this inspection?
Were as built plans of the'system obtained and examined?(If they were not
® El.
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)]
J •. ..f ., w 1. 'ti
t5insp.doc•rev.7t26/2078' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses
Owner Owner's Name
information is Cotuit MA - 02635 February 11, 2021
required for every
page. CityrFown 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 GPD
Description:
2.
Number of current residents:
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
2019= 137 GPD
Water meter'readings, if available (last 2 years usage (gpd)): 2020=98 GPD
Detail:
Sump pump? ❑ Yes ® No
Current
Last date of occupancy: - s .Date
4
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y< 1478 Santuit Newtown Road-4
Property Address
Cara & Paul Meneses
Owner Owner's Name
information is required for every Cotuit MA 02635 February 11, 2021
page. Cityrrown 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. ., etc.): -
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges t :.
Industrial waste holding tank resent? 4 ❑ Yes ❑ No
Non-sanitary waste disch ged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, i available:
Last date of occupan /use: Date
Other(describe b ow):
3. Pumping Records:
Source of information: Owners records:Pumped Fall 2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
r
'How was quantity pumped determined?
Reason for pumping
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses `
Owner Owner's Name
information is required for every Cotuit = MA 02635 February 11, 2021
page. Cityrrown State Zip Code - Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
Y f .
❑ 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
' y
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):. - • "
Approximate age of all components, date installed (If known) and source of information:
System installed 1994 Permit on file at Health Dept
Were sewage odors detected when arriving at the site?. x ❑ Yes No
5. • Building Sewer(locate on site plan): a
Depth below grade feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain)_ 5
n/a
Distance from private water supply well or suction line: 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 ,
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara 8r Paul Meneses
Owner Owner's Name
information is Cotuit MA 02635 February 11, 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: s 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
11.5'x 5.5'x 6' 1500 gallons H-20
Dimensions:
4' .
Sludge depth: _
29"
Distance from top of sludge to�bottom of outlet tee or baffle
4
Scum thickness
101,
Distance from top of scum to top of outlet tee-or baffle
14"
Distance from bottom-of scum to bottom of outlet tee or baffle
How were dimensions determined? Dip tube and tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet pvc tee and outlet concrete baffle in place. Liquid level at outlet invert. Risers installed to bring
covers within 6"of grade. Recommend maintenance pumping within 6:months. Recommend
maintenance pumping every two years with full time use.
t5insp.doc•rev.7/26/2018 Titte 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
1478 Santuit Newtown Road
Property Address }
Cara& Paul Meneses
Owner Owner's Name
information is Cotuit MA 02635 February 11, 2021
required for every
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 t top of outlet tee or baffle
Distance from bottom of s um to bottom of outlet tee or baffle
Date of last pumping: "Date
Comments(on pump' g recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as relat d to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: '
Material of construction: '
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18,
Commonwealth of Massachusetts ' =
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1478 Santuit Newtown Road -
Property Address `
, r
Cara& Paul Meneses
Owner Owner's Name
information is Cotuit MA 02635 February 11, 2021
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information(cont.)-
8` Tight or Holding Tank(cont.),
r
Alarm present: ❑� Yes ❑ No' i
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: ` Date
Comments(condition of alarm and float s itches, etc.):'
9
i
*Attach copy of current pumping contract(required)'Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):Oil
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
One inlet, two outlets. No speed levelers. No solids carryover. No high water staining over outlet
inverts. H-20 DB-5. Installed 3.5' H-20 riser and 18" metal ring and cover to grade.
• - pew¢ .` , t • -
• .. ` •. ♦ } Syr -
a • `
t5insp.doc•rev.7/26/2018 ' Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 12 of 18 W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1478 Santuit Newtown Road '
Property Address
Cara& Paul Meneses
Owner Owner's Name
information is Cotuit MA 02635 February 11 2021
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑. Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump amber, 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:
4 infiltrators w/
® leaching chambers number: stone.
❑ Teaching galleries number:
❑ leaching trenches F. ° 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses
Owner Owner's Name
information is Cotuit = "-MA 02635 February 11, 2021
required for every
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.):
Camera used to locate and inspect leach chambers. Located under asphalt parking area. No vent
found 1" liquid standing in first unit No standing liquid in last unit. No sign of past hydraulic failure.
t:
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 inflo ❑ Yes Ej No
Comments(note condition of oil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): '
a
n
Page 14 of 18
t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1478 Santuit Newtown Road : _ w '
Property Address
Cara& Paul Meneses
Owner Owner's Name
information is MA . F02635 k February 11, 2021
required for every Cotuit
page. CitylTown State Zip Code Date of Inspection .
D. System Information (con0' .",
13. Privy(locate on site plan): ,Y
Materials of construction,-
Dimensions,
. A a
Depth of solids
VO
Comments(note condition of soil, signs of ydraulic failure, level of ponding,condition of vegetation,. "
etc.): .
, e w
77
a
.y
r
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+. _ . a .t •s a .!
r • Form:Subsurface Sewage Disposal System,•Page 15 of 18
t5insp.doc•rev.7/28I2018 r TitlefiOffGallnspection E '
• .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara&Paul Meneses
Owner Owner's Name
information is Cotuit MA '02635 February 11, 2021
required for every
page. Cityfrown 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
l , 3 7 '.S
0
� r
t5insp.doc-rev.72 mis Title s official inspection Forth:Subsurface Sewage Dispose]System Peps IS of 1S
Commonwealth of Massachusetts
Title 5 Official Inspection -Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses
Owner Owners Name
information is Cotuit MA 02635 _ February 11, 2021
required for every —
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) .
15. Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar '
❑ Shallow wells
>5
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record1994
1f checked, date of design plan reviewed: Date
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:
maps.massgis.state.ma.us/oliver.php
You must'describe how you established the high ground water elevation:
Test hole in 1994 found no ground water at 11'. Base of units found at 5.5' below grade. Slope to rear
of property drops well below base of units. No high ground water in area of system.
- F
a Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7128/2018 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
1478 Santuit Newtown Road
Property Address
Cara& Paul Meneses '
Owner Owner's Name R
information is required for every Cotuit MA 02635 February 11, 2021
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® 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 ti
® 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.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 -
I. '
�heck �- � o1D
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
_
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
f
forms on the L � 1
computer, use 1. Inspector: JJ
only the tab key
to move your David D. Coughanowr '
cursor-do not
use the return Name of Inspector
key. Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
�40D City/Town State Zip Code
508 364 0894 1328
Telephone Number. License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
04 t;cj- ' �S December 10, 2009
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 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.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1478 Newtown Road
Property Address
P Y
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. Cityrrown 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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if the
inspector cannot answer Yes to any of the failure criteria listed in Section D on pages 4-5 of this
report. The septic system has been evaluated according to the conditions observed on the day it was
inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
Recommend that laundry line be piped into existing system or abandoned.
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.
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
_
every page. City/Town 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:
❑ 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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
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 1/2 day flow
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
v Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town +State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® 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 water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ '❑, the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area- IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town 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 at issue
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 gpd
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
M 1478 Newtown Road
Property Address
Robert and Jillian Basler `
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
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 Z No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage (gpd)): 33 gpd
9 ( Y 9
Detail:
2008-2009
Sump pump? ,❑ Yes ® No
Last date of occupancy: 2 months agoDate
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:
(Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town 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: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
y Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1478 Newtown Road
1M
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 15+ years. Certificate of Compliance issued 6/20/94 (Permit#94-309)
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.):
Sewer line was not accessible.
S
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: ,
9 ft x 6 ft x 5 ft(1000 gallon)
Sludge depth: 4 in
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 1478 Newtown Road
M
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30 in
trace
Scum thickness
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design Plan
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 not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
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
t5ins•09/08 Title 5 Official Inspection 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
,M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. CityTTown 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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete y ❑ 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town 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 at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. A
bucket of water was poured into the distribution box and was observed to pass through in a rapid and
unobstructed manner. No staining above normal operating level was observed.
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:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA . 02648 December 10, 2009
every page. City/Town State , Zip Code Date of Inspection
D. System Information(cont.)
Type
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 1
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into
the distribution box and was observed to pass through in a rapid and unobstructed manner, and could
be heard splashing down into the leaching gallery.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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-09108 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
�^M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
r
l
L
_ F
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10 2009
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: 30+
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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 30 feet above
groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 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
,M 1478 Newtown Road
Property Address
Robert and Jillian Basler
Owner Owner's Name
information is required for Marstons Mills MA 02648 December 10, 2009
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
V'
Commonwealth of Massachusetts ,
Executive Office of Environmental Affairs y
Department of
o A'
Environmental Protection GRd
� .
� C9 ��
Wllllam F.Weld ". �, Trudy Coxe
GoMrnor Bra *Wy
Argeo Paul Celluccl David BStruhs,
oaU.Gowefnor commmalwWr
o .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
S' - CERTIFICATION
Property Address: 1478 `Newtown Rd. , COtuit Address ofowner. Charles Phillips
Date of Inspection: (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6
. W.E. Robinson Septic Service-
P.O. Box 1089 Centerville MA
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
P 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 Zames
disposal systems. The system:
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: t'`_(�r/ Date:�� —��-9 y
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY:
Check A,B, C,or D:
Al SYS PASSES:
7roe found information w not any n loch indicates that the system violates any of the failure criteria as defined.in 310 CIdR 15.903.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indira 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, 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 conforming septic tank as approved
by the Board of Health.
(rev ed 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 4 FAX(617)SWI049 a Telephone(617)292-5500
�i Printed on Recycled Paper
t
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1478 Newtown Rd. , Cotui t
Owner. Charles Phillips
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(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 pipes). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
CI FUR ER 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 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 a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
AFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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.
3) O ER
(revised 11/03/95) 2
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1478 Newtown Rd. , Cotui t
Owner. Charles Phillips
Date of Inspection: /! — G - C'9
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
his determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
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-wen with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
conform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE TEM FAILS:
e following criteria apply to large systems in addition to the criteria above:
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:
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 H of a public
water supply well)
The owns r operator of any such system shall bring the system and facility into.hill compliance with the groundwater treatment program
requirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for ftuther information.,
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Add,.= 1 478 Newtown Rd. , Coutit
Owner. Charles Phillips
Date of Inspection:
Check if the following have been done:
ping 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 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 N/A.
facility or dwelling was inspected for signs of sewage back-up.
4Ae system does not receive non-sanitary or industrial waste flow
_L/fhe site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
4he 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.
_/'7he size and location of the Soil Absorption System on the site has been determined based on existing information or
l/aappproximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 478 Newtown Rd. , Cotuit
Owner. Charles Phillips
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow 3 3L gallons
Number of bedrooms:
Number of current residents: 6
Garbage grinder(,yes or no):AVVO _
Laundry connected to system(.yes or no): Ye S
Seasonal use(yes or no):_!Lt-12A
Water meter readings,if available: 1 9 9 5 — 1 0 5, 0.0 0'g a l s .
Last date of occupancy:�1✓�
COMMERCIAL/INDUSTRL4LL:
Type of establishment:
Design flow:_gallons/day
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 source of information:
System pumped as part of inspection: (yes or no)li_o
If yes,volume pumped: gallons
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)and source of information: Ll 31/Z
Sewage odors detected when arriving at the site: (yes or no) 1 vv
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C'
SYSTEM INFORMATION(continued)
Property Address: 1478 Newtown Rd. , Cotui t
Owner. Charles Phillips
Date of Inspeetion:
SEPTIC TANK_d
(locate on site plan)
Depth below grade:
Material of constriction l000ncrete_metal_FRP_other(explain)
Dimensions: C 4
Sludge depth: 3,
Distance from top of sludge to bottom of outlet tee or baffle: Q
Scum thickness: 0 —3 ' c
Distance from top of scum to top of outlet tee or baffle: ,
Distance from bottom of scum to bottom of outlet tee or baffle: /a-)3 '
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relati9n to outlet invert,structural integrity,
evidence of leakage,etc.) /D G d G; ! D r sti
(i E.TRAP:_
(locate o site plan)
Depth be w grade:
Material f construction:_concrete_metal_FRP_other(ezplain)
Dimens' ns:
Scum ess:
Distaaoe m top of scum to top of outlet tee or baffle:
Distance m bottom of scum to bottom of outlet tee or baffle:
Comments:
(recomme tion for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,strucbual integrity,
evidence leakage,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: 1478 Newtown Rd. , Cotui t
Owner. Charles Phillips ,
Date of Inspection:
TIG R HOLDING TANK:_
(locals on site plan)
Depth be grade:
Material construction: concrete_metal_FRP_other(explain)
Dimensio
Capacity: ons
Design w: sallons/day
Alarm 1:
Comments
(condition f inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BO&P
(locate on site plan)
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,etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddresa: 1 478 Newtown Rd. , Cotuit
Owner. Charles Phillips
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on she plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:_
leaching chambers,number: "I
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow oesspool, number: /
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation etc.) LI 16
�. /fie m J'C^ S
CESS _
(locate on si plan)
Number and tion:
Depth-top of li 'd to inlet invert:
Depth of solids yer-
Depth of scum r:
Dimensions of pool:
Materials of co ction:
Indication of dwater:
infl . (cesspool must be pumped as part of inspection).
Comments: (note n 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 oo n of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
property Address: 1478 Newtown Rd. , Cot iut
Owner. Charles Phillips
Date of Inspection
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
117
i
of
1
DEPTH TO GROUNDWATER
Depth to groundwater: 1 k feet
method of determination or approximation: G 7&0 i 40jc:s
(revised 11/03/95) 9
n
a
µY • I
CO\I�10\«'E.ALTH OF RLASSACHt'SETTS -
EhECt;TI%rE OFFICE OF EN-VIRONMENTAL LVFAIF,
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE Cl'INTER STREET. BOSTON \Lfi 02106 1617 242-:ifiu�i
•. TRUDY CO\E
. Secretan
ARGEO PAUL CELLUCCi DAVID B. STRUlis
Conuniss:c;.,e:
Governor
lM�� �� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM +
1 PART A
y CERTIFICATION
Pr Address: 1�11 U V" r �1��
�y Name of O�jner
�St1"�j(( jddress of Owner: 6c-,k`, (4 z'3
Date of Inspection: '7`W�C( ,�,+ t / , '/ w,
Name of Inspector:(Please Pri )I [ C�+y c�C if�EC_K U
I am a DEP approved system inspector pursuant to Section 15.1340 of True 5(310 CMR 15.000)
Company Name: lq&Lt A r /k� 'K! r. k� e- k— F
Mailing Address: ?,t2 A,, t z 77,'gl4- M1tS—NJ2 r� , 12_,4,
Telephone Numbef: ESQ L44 7
CERTIFICATION STATEMENT t
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:
Passes .
_ Conditionally Passes
_ Needs Further Evaluation the Local Approving Authority
Fails
Inspectors 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 ttte
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
- s i
XI A
tisT..4999
a
revised 9/2/98 Page IorII
0.n Printed on Recyckd Paper
A
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
`Toperty Address:
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, o/ 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 o has provided the system inspector with a copy of a Certificate of
_ operator
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 exfiltratidn, 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 r
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more then 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 P2ge2Of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 ystem is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 31 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND S FETY 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 sal marsh.
• t
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC ATER SUPPLIER,'IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption syste (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 sys m and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption sy ern and the SAS is within 50 feet of a private watertupply well.
_ The system has a septic tank and soil absorption s stem and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water an ysis for eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and a presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distan (approximation not valid).
3) OTHER
revised 9/2/98 - Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4
PART A
CERTIFICATION (corronuedl
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or -No" to each of the following:
conditions exist as describ din 310 CMR 15.303. The basis for this
I have determined that one or more of the following failure
determination is identified below. The Board of Health should be contacted to deter ine what will be necessary to corre *. the failure.
Yes No
_ Backup of sewage into facility or system component due to an overlo ed or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or sur ace waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert du to an overloaded or clogged SAS or cesspcol
Liquid depth in cesspool is less than 6" below invert or avail ble volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipefsi.
Number of times pumped_.
_ Any portion of the Soil Absorption System, cesspool r privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 fe of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is within a Zo e I of a public well.
Any portion of a cesspool or privy is within 5 feet of a private water supply well.
Any portion of a cesspool or privy is less•th n 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the II has been analyzed to be acceptable, attach copy of well water analysis for
'coliform bacteria, volatile organic compo ds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or 'No" to each of the Ilowing:
The following criteria apply to large systems i addition to the criteria above:
The system serves a facility with a design ow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment be ause one or more of the following conditions exist:
Yes No
the system is within 400 fe t of a surface drinking water supply
the system is within 200 eet of a tributary to a surface drinking water supply
the system is located i 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 sy em shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further i formation.
revised 9/2/98 Page 4oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property
Address: /"
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
XPumping information was provided by the owner, occupant, or'Board of Health.
-lam. _ 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 N,A.
t
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow. ,
_ The site was inspected for signs of breakout. t
i
All system components, excluding the Soil Absorption System, 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 it unacceptable)
Ilk 115.302(3)(b)1
The facility owner (and occupants,if different from owner) were provided with information on the proper r aintenaara-0f
SubSurface Disposal Systems.
revised 9/2/98 Page Sof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1, SYSTEM INFORMATION
'roperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):0.3
Total DESIGN flow�0
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no): If yes, separate inspection required
Laundry system inspected (yes or 6
Seasonal use (yes or no)&13— - \\
Water meter readings, if available (last two year's usage (gpd): N
Sump Pump (yes or no):z
Lest date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: 9pd ( Based on 15.2031
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 source of information ��
System pumped as part of inspection: (yes or no)-`e�
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
—w- Single.
cesspool� ool
p
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: ✓ J bi Vy2
s detected when arriving at the site: (yes or nai[�
Sewage odor 9 ,
revised 9/2/98 Page 6(if ll
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) vl�
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 p n)
N
Depth below grade:,
Material of construction: &concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance _(Yes/No) t
Dimensions: (,W6�1�1
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle: d�
Scum thickness:_ �i
Distance from top of scum to top of outlet tee or baffle: G(
Distance from bottom of scum to bottom of outlet tee or ba fle: lam_
How dimensions were determined:
r �
omments:
(recommendation for pumpin , condition of let and outlet.tlees or baffles, deptth of liquid level in relation to tie invert tru ural inte rity,
Wde a of leakage, etc.)
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions: _ ..
Scum thickness: f outlet tee..
or
Distance from top of scum to top o baffle:
Distance from bottom of scum to bottom of outlet tee or baNle:
Date of last pumping: w
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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
rroperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: 1kb(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(ex 1.plain)
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:�S
(locate on site plan)
Depth of liquid level above outlet invert:-2 1l 43�.)Q'T � L
Comments: r
(note if level and distn',�u ion r equ 1, evi en"of solids carryov evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,-condition of pumps and appurtenances, etc.)
revised 9/2/98 page sorit
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�(, � SYSTEM INFORMATION (continued)
Yoperty Address:-to !U pttN` '-(�
Owner:
Date of Inspection: 4ts
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excav Uon not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:.
leaching chambers, number:�M�a6
leaching galleries, number._ k
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 of ponding, damp soil, condition of vege ion, .) C ,
CESSPOOLS: "
(locate on site plan)
4
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer. i
)epth 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 srte 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 9orII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
'roperty Address:
lwner:
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)
o ,
z
3 � r .
a
t
A�-�s ` �� q�,
revised 9/2/98 Page 10of11
r _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address:
Owner:
Date of Inspection:
i
NRCS Report name ---
Soil Type_ ----- ---
Typical depth to groundwater____._ _ ___
USGS Date website visited �yx
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar "
Shallow wells
Estimated Depth to Groundwater —JFeet
Please indicate all the methods used to determine High Groundwater Elevation:
. t
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 establiphed the Hi h Groundwater Elevation. (Must be completed`) `
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revised 9/2/98 Page 11of11
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APPROVED THE COMMONWEALTH OF MASSACHUSETTS F�a.... :
A Barn 3Conte BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirati for Di-nVasal Work,i Tomitrnr#iun jilerntit
Application is hereby made for a Permit to Construct ( ) or Repair (`/f an Individual Sewage Disposal
System at:
Location-Address or Lot No.
�Gs�e -. ..
w .............__._..� -�. Owner -CQ�----- � -
ddyc�s
----..-------------------•- CA
U`S� � ..... �{ � ��-------------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms.___.._..._-________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
d
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity_/Q6 U.gallons Length---------------- Width---------------- Diameter---------------- Depth................
x 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........................................
,_l
Test Pit No. I................minutes per inch Depth of. Test Pit-------------------- Depth to ground water........................
li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
R+ ---------------------------------------------------------------------------------------•-•-••---•---.........................................................
0 Description of Soil........................................................................................................................................................................
x
U ------------------------------------------•-----••---•--------------------•-------------------------------------------------------------•-------•-----------•---------------------•---...-------•••----
W --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------..---•----...----
U Nature of Repairs or Alterations—Answer when applicable__._ .��`r�.....CeSS�(�L.:........W�
-----------------
_...
�C�_CCU �• ,�..---F en ..V.......... Q>V<....t...W...,cx.. .---.._ c�,' .......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undamig=d further agrees not to place the
system in operation until a Certificate of Compliance has beep is"su the board of health.
LO
t .a0 USigned .. .... .........
Date
Application Approved By ... .... ----- --------- ---- --------
---- ------ ------------------....------------------------- Dace
Application Disapproved for the following reasons- ----------------------------- --- ----------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------- . .... ...................
-Date
Permit No. l ���''
/ ... ........ Issued ..... ................. e.................
Dare
No.-••-,-• 0�--- � r FE$.............. ...�-sue
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lZ,S,, ,cyyTOWN OF BARNSTABLE
Appliratiou for Diopoottl Workii Tonotriir#inn Errant
r'
Application is hereby made for a Permit to Construct ( ) or Repair (`%f an Individual Sewage Disposal
System at:
- --.. -----)e..............................
�--------------------.............................................................
Location-Address or Lot No.
--------------------------------- Cam"^--e-
........................................................
Owner Ca Add e s
MW .............................................. �`5 .... ( -- .... ---V LG� .._ I'�
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms-__---�------------------- -- _Expansion Attic ( ) Garbage Grinder ( )
........................... No. of ersons----_-._---_--_-_-_--------. Showers — Cafeteria pa,, Other—Type of Building p ( ) ( ) �
a' Other fixtures ............................... . .
W Design Flow.................. .........................gallons per person per day. Total daily flow--------------------------------------------gallons.
P4 Septic Tank—Liquid capacity_./Q G U.gallons Length---------------- Width---------------- Diameter---------------- Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
• x
3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 11'
Percolation Test Results Performed by.......................................................................... Date--------------------------------------..
,aa Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water_.__=._---.---_--_-----.
(i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water..._-__---_.__--.._-___.
a' ....---•-•••----------------••---•---•••--••----•-•------••--•-••-•------------------.....------•............................................................
DDescription of Soil........................................................................................................................................----......--........ ::..` .
1 ..
U
�I .....................................................................................................................................................".........__......................,...............
U Nature of Repairs or Alterations—Answer when applicable.-.-_ 1� ._____w
-- -- -----
4
Agreement:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned-further-agrees not to place the
system in operation until a Certificate of Compliance has be issu �b_y the board of health
Signed ........� 611
Dace
Application Approved By .... ..... 6'..��
Application Disapproved for the following reasons: ...............................
---------------------------------------------------------------------------------------------------------------- ----------------------- ..............---....-------------...............------ ------------------------------- --
�D- /a--y Dam
Permit No. yxf//-' ��...1�... ........ Issued ...........- -
.......... ( ................. Date ......................{...........
----- --------------------------- -------------------------------
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertifirate of Compliance
THIS IS TO,CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ----------- -------------------------------------..-------------------_--_--------.--------------------------...--------------------...._......-----------_-----------------------
nsrdle
at ........._`��.. .-----.. .W. - �.--------...-Zj_. I r-----------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _... .Q...�C.. dated ------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 4E CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. � �
„ i - ----- Ins ector '----... - -...Z ' . :: �. =
DATE....... _..... ........ - � p
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE FEE... -
No...... ............
Biquioat ork�o Tonvtrurtiott "rrinit
Permission is hereby grantedd. .....�G V���_.`'���. �--------------------------•-----------.........---•-----...._.....---•--...........---
to Construct ( ) or Re air (Kan Individual ewage Disposal System
atNo....-----•V��.... !us.j.�-- �-C-..------•-----.-------- -ee ------------------------------- ---•-•--•--------••-••..............
Street y /�
as shown on the application for Disposal Works Construction Permit ��"_�:?GT��Dated.._��.��......:....`
-
Board of Health
DATE....... ...........................
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS
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DRAWING TYPE:
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/G1 GOOF TAI"r PLAN
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