HomeMy WebLinkAbout0044 KING ARTHUR DRIVE - Health E44 KING ARTHUR DRIVE, OSTERVILLI
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c Commonwealth of Massachusetts
+T Title 5 Official Inspection Form _
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
V�
Property Address
Ricky Hubbard `
Owner Owner's Name
information is
Osterville Ma 02655 5-5-2020
required for every --
page. City/Town Y 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.
Impg out
When
fillip out forms A. Inspector Information &
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
ry Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported 4,elelow is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes _
3. ❑ Needs Further.Evaluation by the Local Approving Authority
4. .❑ Fails
Brett Hickey Digitally signed by Brett Hickey
oate:2020.05.07or32:20-oa•oo' 5-5-2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
♦ V
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
1
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:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑. Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k
44 King Arthur Drive
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or.high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will' -
pass inspection if(with approval of Board of Health): -
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑`N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N , ❑ ND(Explain below):
r
❑ 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):
4
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 - Title 5 Of dal Inspection Form:Subsurface Sewage Disposal System•Page 3 of,18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
~ � 44 King Arthur Drive
V
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
The system has a septic tank n❑ a and SAS and the SAS is within 50 feet of a private water
Y P
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El a Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
4
Commonwealth of Massachusetts
,9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
v"
Property Address
Ricky Hubbard
Owner Owner's Name
information is required for every Osterville Ma 02655 5-5-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ID than
depth in cesspool is less than 6"below invert or available volume is less
than '/z day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ [El Any portion of the SAS, cesspool or privy is below•high ground water elevation.
❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.:
❑ E 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 16,000 gpd.
For large systems, you must indicate either"yes" or''no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply -
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(interim Wellhead Protection
El ❑` Area—IWPA) or a mapped Zone II of a public water supply well'
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
I14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no" for each of the following for all inspections:
Yes No
❑ El Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
ElWere as built plans of the system obtained and examined?(If they were not
available note as N/A)
El 0 ' Was the facility or dwelling inspected for signs of sewage back up?
❑ .Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
E ❑ 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?
❑ a Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
El ❑ Existing information. For example, a plan at the Board of Health.
❑ Q Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
r
Y '
Commonwealth of Massachusetts _
p Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
�l Jai
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 t 5-5-2020
required for every .
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms(design): - Number of bedrooms(actual): 3
330/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
-Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes 0 No
Does residence have a water treatment unit? ❑ Yes rul No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection Yes 0 No
information in this report.)
Laundry system inspected? Yes ❑ No
Seasonal use? ❑ Yes rul No
Water meter readings, if available(last 2 years usage (gpd)): See below
Detail:
2018- 20,000gallons 2019- 39,000gallons
Sump pump? ❑ Yes ❑■- -No -
Last date of occupancy: currentDate
1 _
t5insp.doc°rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
' , v
c Commonwealth of Massachusetts
6F Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l;
0 44 King Arthur Drive
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit resent.p ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t '
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
I
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
0 Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1978 per plans
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
° 1'3"
Depth below grade: feet
Material of construction: -
❑ cast iron ❑■ 40 PVC ❑other(explain):
Distance from private water supply well or suction line: Town waterfeet
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
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I;
44 King Arthur Drive
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
3"
Depth below grade: feet
Material of construction:
■❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 000gallons
4"
Sludge depth:
32"
Distance from top of sludge to bottom of outlet tee or baffle
311
Scum thickness
G 11
Distance from top of scum to top of outlet tee or baffle V
1311
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
i
Commonwealth of Massachusetts
�d I Title 5 Official Inspection Form T
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f
44 King Arthur Drive }
�V
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:. NA
Material of construction:,
❑ concrete ❑ metal ❑fiberglass - [:].polyethylene ❑other(explain):
Dimensions:
Capacity:
x gallons
Design Flow: r- -
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
V�
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0"
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.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,w 44 King Arthur Drive
V
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
" 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.
(1 ) 6'x6' pit
0 leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ - innovative/alternative system .
. .. _ Type/name of technology: _ ..-
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Pit was 50% full when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
. F
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
44 King Arthur Drive
Property Address
Ricky Hubbard _
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
13. Privy (locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1
44 King Arthur Drive
V�
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
Rear
Li
C2A B
2
Al-10' B1.6'
A2.12' 62.11'
A3.15' B3-16'
0
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
v
Property Address
}
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑■ Check Slope
• t
0 Surface water
❑■ Check cellar
❑■ Shallow wells
Estimated depth to high ground water: No GW @12'feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record'
12-14-1978
If checked, date of design plan reviewed.- Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page1'"
t5insp.doc•rev.7/26/2018 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
m
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 King Arthur Drive
v
Property Address
Ricky Hubbard
Owner Owner's Name
information is Osterville Ma 02655 5-5-2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
■❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
0 C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
t
4 (Failure Criteria)and 6 (Checklist)completed
D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
No. / ...... Fps.. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
1 " .......--- oF_,a ................... ...
App iraftun for Biipaaaa1 Workii Toamtrurtion Vamit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System<at ....1� -- -
Ad. . G'
Lo- 'on- dress or t.No.
- .. . .. ............................... 'C1= _.�Q 41, -; . .. : ......
Qwner Addr
Wn. !P�.._........ ................. .......;--------- 7Y'�."_."'--._....
a Installer Address _
ype of Building Size Lot.. _ .....Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (getj
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixt es ............................
W Design Flow............67............................gallons per person per day. Total daily flow............ .................gallons.
WSeptic Tank—Liquid capacityA~. ..gallons Length.......7..,__- Width......&I ...... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total .Length........._..._...... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter........ ......... Depth bell inlet.__. ..... g q.
�!.._. Total leaching area_ `�.___.1..____s ft.
Other Distribution box ( ) Dosing tank ( ) -7 �'
'—' Percolation Test Results Performed by _�2N���'` <-__! ,�_7 1_r............. Date_.._ _�_I�I.2_ ..............
Test Pit No. 1..... ---minutes per inch Depth of Test Pit____________________ Depth to ground water..,Ql6t1l __ T �z-
(T, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------ -•--- = ----------- --- .
O Description of Soil-Q-_-L � ..............•--•---�.... .---- 1_ .... --
x
W -•----------------------------------•-------•------------------•--------•--------------••-•-•----------------------....----- ----------------------•------------......................................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
•---•-----------------------•---.....----------------...------------------------------....••--------•-•-•---•----•-------•----------.-----------•-•---•---•------•--••--------•------•--•--------•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI I'L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of h alth.
S' ned. -------- ......................
....---•--.......... ..,,� ..._
n ate
Application Approved By......� E . 7
Date
Application Disapproved for the following reasons:-----•----- --•---•-•--••-----------•-----------••------•--------------------•----. ............................
--------------•-•-•-••----...•-•--•--......--•--•....----._..................._.......•-•---•----------•----•-----•---•----•----•-----------------------------•----------------------------- -----
Date
Permit No--------------------------------------------- `1 ---• Issued.... y�-
Date
717
No.. ....... Fmc e?3..'...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Y -
.O F
Aptira Lion for Elhip ii al Works Ton,strnrtinn Frrutit
=,. Application;;is hereby made for a Permit to Construct ( or Repair ( ) an Individual. Sewage Disposal
System at:
..... ........_ . ._ -- .. ..
......................... .....•....------•--•-•• ......------ -...-----. --............----
L ion- dress 7 0 t No
Owner Add
a
a'. ...... . ..... . :- 'p...:__..._..._._.....---..... . .>.,x :�"'-•-•-- ..... ..................................................
In9taller Address
d ype of Building Size Lot_!;.1.3A.....Sq. feet
U Dwelling—No. of Bedrooms............ __________________________Expansion Attic ( ) Garbage Grinder
Other—T e of Building No. of wgons____________________________ Showers — Cafeteria
Q' Other.fix res ------•••-•-•••••--•-••••••---•• - . - ...............................
Design Flow.......... _____.........................gallons per person per day. Total daily flow............ •. f A_.__._._________..gallons.
9 Septic Tank—I I laid capacityi�tl _gallons Length_._.__'' _,.Width . DianReter __-;__________ Depth _____________
Disposal,. rench. j No. _____ g q.
W -al _.___. Width____ ______________ Total Rength � Total leaching area_.-." �" � s ft.
xf
Seepage Pit No ______�__ Diameter....... Depth below�'' i'nle _- _ __ Total leaching area.srPl_ 'stlt.
Z Other Distribution box ( ) fi Dosing tank % � ,.
`" Percolation Test Results Performed by o� 1.... •_.. _�/l ` -X ______________ Date--_1__- " ..............
a l o ?( �Z
,-,-a Test Pit No. 1.....-2-__._minutes per inch Depth of Test Pit____________________ Depth to ground water:/1/-_N!,f _.__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.:____:.._..____._:__._-
(� }
Description of Soi {« p-��_._br -•.......... ......
r,ti
V ---------••----------------•-- ---------- ---•-------•----- -
W
UNature of Repairs or Alterations—Answer when applicable____='_ -------------------------------------------------_......................................
°.
Agreement: � �fSY .
The undersigns: agrees to install theworedescribed Individual Sewage Disposal System i�n eiordanke with
the provisions of TI'T L. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has .�een issued by the,board of lth ;
r ed
�r_APPlication Approved BY ....
........_
Date
Application Disapproved for the following reasons:------••-• •-•--•-••-•-•--•-•••---•---••-------•---•-•----•---•••-•-------•--.................................
:_..--,•_------- .............................•-•----•.__••-•-••-•--••• ---•-
Date
Permit No. Issued `-------------...........g.......................
Date
i
� 3:a
THE,COMNIONW, ALTH11 F MASSACHUSETTS
'0
BOARD OF HEALTH
Q !yr .............OF... G + .................................
Trrfifiratr aaf TI—lutpliFanrr
THI S TO CER Y, Th t the,Individual Sewage Disposal System constructed ( or Repaired ( )
by -
01
nstaller
has been installed in accordance with tl provisions of TI` 5 of The State Sanitary Code as described„inAlie,,.
application for Disposal Works Construction Permit No._ __ '.___� ________________ dated__.iJ7''f '.::_ ---------------
THE
ISSUANCE Of. THIS CERTIFICATE,SH*LL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.---....-•-•-t-l::: ....................................... Inspector -- �.., -------------------
THE COMMO�)tWEALTH- C3F MASSACHUSETTS
n BOARD' OF HEALTH
N . :.--_. FEE.__91..............
Dispia rk nil ion rranit
Permission is he by granted........ •. •••=----•••-••• __• ...��---�^'��'=---------------------------------------•-----._._.....-•---.......:_...._..
to Con'stru t ( or epair . n Vivid =ag isposal System
atNo .l .. . _. ------ -r•------------------------------------------------------
Street"
as shown on the application for Disposal ���orks Constructions er No. __ �Yf_' -7
,,/
•••••. Da e •-- ----- • ---•-••. .
oa of
DATE----- C
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FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 John Grad
D.E.P. Title V Septic Inspector
IF . 1 l`� �� r—J P.O. Box 2119
! 7 l Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART A
CERTIFICATION
Property Address: 44 King Arthur Dr.Osterville Address of Owner:
Date of Inspection: 3/12/98 (If different)
Name of Inspector: John Graci Mrs.Kaprielian:251 North Main St.Natick MA 01760
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes f This Inspection Is based on criteria defined In Title V
— Conditionally Passes code 310CMR16.303.My findings are of how the system is
performing at the time of the inspection.My inspection does
— Needs Fur er aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity ofthe
Fails septic system and any of Its components useful life.
Inspector's Signature: Date: 3112198
e The System Inspector shall su mit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-, or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
r -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112199
_ Sewage backup or.hreakout.or. hiah.static water level observed.in.the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced ;
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ,
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS a
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 SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine,distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
_ 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 this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No •
_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool. n
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 King Arthur Dr.osterdle
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112199
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions•exist:
Yes No
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
+ 2
(revlaed 04127197)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
-x— — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System, have been located on the site.
x 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.
x _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the.proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)J
(revlsed 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Add ress: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g•p•d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: 0 5,
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yea
Water meter readings, if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL: '
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: nrs
Last date of occupancy: n1a
OTHER: (Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
VA Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
1979 t
Sewage odors detected when arriving at the site: (yes or no) No
(revlsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
SEPTIC TANK: x a
(locate on site plan)
Depth below grade: 3"
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: t.eS°11e7"w4-10"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:s"
Distance form bottom of scum to bottom of outlet tee or baffle:0
How dimensions were determined: measured
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.)
Septic tank and all components are structurally sound and functioning properly.Recommend pumping every two years.
GREASE TRAP: „
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:rda
Date of last pumping;d.
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.)
rda _ ..
BUILDING SEWER:
(Locate on site plan)
Depth below grade: e-
Material of construction:_cast iron 40.PVC_other(explain)
Distance from private water supply well or suction lin0o ^
Diameter: 4"_
Qmments:(conditions of joints,venting,evidence of leakage, etc.)
(revised04R7197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add Arthur Dr.Osterville
Address: 44 King
Owner Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nia
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: wo
Capacity: n1a gallons
Design flow: nra gallons/day
Alarm level:_n1a Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rya
DISTRIBUTION BOX: x
F �
(locate on site plan)
Depth of liquid level above outlet invert: liquid levelwithboftomofpipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
D$ox Is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)Nu
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revlsed 04127197)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
nfa
Type:
leaching pits, number: one tOhO CJ C..'.
leaching chambers, number:rda
leaching galleries, number: ria
leaching trenches, number,length: rda ..
leaching fields, number, dimensions:rda
overflow cesspool, number:nla
Alternate system: n1a Name of Technology:_rva
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Leach pit and all components are structurally sound and functloning properly.System is cuff ently empty.
CESSPOOLS:_
(locate on site plan) „
Number and configuration:
Depth-top of liquid to inlet invert:rda
Depth of solids layer: nla
Depth of scum layer: Wa
Dimensions of cesspool: nla
Materials of construction: nla
Indication of groundwater: ria
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) t
rda
PRIVY:_
(locate on site plan)
Materials of construction: rda Dimensions: Na r
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n1a
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
44 King Arthur Dr.Osterville
Mrs.Kaprielian:251 North Main St,Natick MA 01760
3112198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
a
La
10
tj C
OD
R
EA
(revised04127197) Page o! a0
!
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
44 King Arthur Dr.Osterviile
Mrs.Kaprielian:251 North Main St.Natick MA 01760
3112199
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
(revlsedO 27197) Page 10 of 10
Conunonwealth of'Massachusetts
Executive Office of Enviromlental Affairs
Dept. of Environmental Protection
One winter Street Boston Ma. 02108 •Jolui Grad
' D.B.P.,Title_V septic Inspector
P.O. Box 2-119
Teaticket, MA 02,536
WILLIAM F.WELD (508)564-681�,•
Governor
ARGEO PAUL CELLUCCI - �+
Lt.GovernorJVI AR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM to J 1998 Ct1
PART A,, `� NOFBARNSTABIE
CERTIFICATION fd' H`A1T,y0EPT
Property Address: 44 King Arthur Dr.Osterville , , \CO t~ S Address'of Owner:
Date of Inspection: 3/12/98 (If different) 8
Name of Inspector: John Graci Mrs.Kaprielian:251 North Main St.Natick MA`01760`7``'�_
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system: _
x Passes This Inspection Is based on criteria dented In Title V
code 310 CMR 16.303,My findings are of how the system is
_ Conditionally Passes performing at the time of the inspection.Myinspectiondoes
Needs/Fuer aluation By the Local Approving Authority not impyany warranty or guarantee orthelongevityofthe
Fails septic system and any of Its components useful life.
Inspector's Signature: Date: 3/12198
The System Inspector shall su copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303, Any failure criteria not evaluated are indicated below.
COMMENTS:
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.'
Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exhltration, 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.
(revised 04127)97)
One Winter Street •;Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: "King Arthur Dr.osterville
Owner: Mrs.Kapriellan:251 North Main tit.Natick MA 01760
Date of Inspection:3112198
_ Sewa4e backup or.breakout.or. high.static water level observed.in.the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or,obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed „
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 SAFETY AND THE
ENVIRONMENT:
F
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
_ 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 this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of 111e ground or surface waters due to an overloaded or dogged
cesspool.
SAS is in hydraulic failure.
(revlsed 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 King Arthur or.osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112199
D]SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: x
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revlsed o4127197)
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
,c_ — Pumping information was requested of the owner,occupant,and'Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x.,
x As built plans have been obtained and examined. Note if they are not available with NIA.' +
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow. n
-x— — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x 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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)]15.302(3)(b)]
(reYleed M7197) - -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION V
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 9 P d./bedroom for S.A.S.
Number of bedrooms: 2 ,
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yea
Seasonal use(yes or no): Yea
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:o gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No '
Water meter readings,if available: nre
Last date of occupancy: nla
s.
OTHER:(Describe) We
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information.'
rya
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:9 gallons
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date Installed(if known)and source Information:
1979
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04.27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 King Arthur Dr.Ostervllle
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3112198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 3"
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list ageL nla . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: 1.e15^H57^w4.10^
Sludge depth:2.,
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6^
Distance form bottom of scum to bottom of outlet tee or baffle:o
How dimensions were determined: measured
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.)
Septic tank and all components are structurally sound and functioning properly.Recommend pumping every two years.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda -
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rva
Date of last pumpingrda
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.)
rda ,-
BUILDING SEWER:
(Locate on site plan)
Depth below grade: e'
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction linetovm
Diameter. 4 a
Qmments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) "
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01760
Date of Inspection:3l72198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nra
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nia
Capacity: nia gallons
Design flow: nia gallons/day
Alarm level:_nra Alarm in working order?_Yes No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.) a
rda
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: liquid level with bottomorpipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
D-Box Is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
nia
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 King Arthur Dr.Osterville
Owner: Mrs.Kaprielian:251 North Main St.Natick MA 01780
Date of Inspection:3112l98
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: one t0t,�p C c,--V.C(`
leaching chambers, number:nra
leaching galleries, number: We
leaching trenches,number,length: nia
leaching fields,number, dimensions:We
overflow cesspool, number:nla
Alternate system: rd Name of Technology._nia
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Leach pit and all components are atructuraly sound and NncUoning properly.System Is currently empty.
CESSPOOLS:
(locate on site plan)
Number and configuration: nia
Depth-top of liquid to inlet invert: rria
Depth of solids layer: nia
Depth of scum layer: nra
Dimensions of cesspool: nia
Materials of construction: nia
Indication of groundwater: We
inflow(cesspool must be pumped as part of inspection)
We
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,•condition of vegetation, etc.)
nia
PRIVY
(locate on site plan)
Materials of construction: rde Dimensions: nla
Depth of solids: nia
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
We
pevleed041271971 - , -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
44 King Arthur Dr.Osterville
Mrs.Kaprielian:251 North Main St Natick MA 01760
3112198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
44 King Arthur Dr.Ostervllle "` V
Mrs.Kaprielian:251 North Main St.Natick MA 01760
3112199
r '
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators,.installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
(revlsed0427197) Yap• l0 of 10
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