HomeMy WebLinkAbout0077 MILNE ROAD - Health 77 Milne Road
Osterville p
A= 118-021 I
° WN OF BARNSTABLE
CUT `
LOCATION 7 7 A acl0 SEWAGE# 0101`I'O 50
VILLAGE OSTerVi)le, MA ASSESSOR'S MAP&PARCEL#
INSTALLER'S NAME&PHONE NO. Tom K e n neU U 44 3 61-7/7 7
SEPTIC TANK CAPACITY j,5OTN_/0 .
LEACHING FACILITY: (type)3-soo.nal N-20 y il'k 4 sT°,'s`ize) 3")X 13
NO.OF BEDROOMS 3
OWNER Kevin WIJIILIhns
PERMIT DATE: � 5/ COMPLIANCE DATE: 3/13/0
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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TOWN OF BARNSTABLE
LOCATION .`., SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT -r02/
INSTALLER'S NAME&PHONE NO'..-
SEPTIC SEPTIC TANK CAPACITY L5 O \'
LEACHING FACILITY: (type) fWS)J 1 (size)
I
NO. OF BEDROOMS
BUILDER OR OWNER How
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: 71
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching:Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by A W Q LDS
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NO.i Q �Jw THE COMMONWEALTFJ OF MASSACHUSETTS. FEE d r
c-� �,A ABOARD OF HEALTH C�.
toy ° � OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System [:]Individual Components
rcel# � � ddress
Installer's Name Designer's Name
Address � wAcles� 16/77
�iCo J�fa Z"Q1177 ®®
Telephone Telephone#
100,
Type of Building: Lot Size 00t � Sq.feet
Dwelling—No.of Bedrooms Z Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(m' .r uired) gpd Calculated design flow gpd Design flow provide D gpd
Plan: Date 1 J .2.Z Number of sheet Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator -. Date of Evaluation
DESCRy)aI ION OF IRS OR ALTERA IONS
9
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ate
Inspections Kj Ci 2 �L
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
S .
r 7 ;
No. �)d / wJ THE COMMONWEA-LL�T-� OF MASSACHUSETTS FEE ,
B0ARD� F HEALTH C y,
-OF'
APPLICATION FOR.DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( p,Abandon ( ) ❑Complete System ❑Individual Components
`� ,` g�a[ion � d� ,',nv�-O•J,wner's"yIC"{a_ _me��,��
` r,,�, Z ,6,,,,�, 1/ s, / i Address t:. :✓
f-AQ%✓_I
/ Installer's Name Designer's Name
Address Address «
Telephone# Telephone#
Type of Building:, J��1�`l v Lot Size at Sq.feet
Dwelling 'No.of Bedrooms _ Garbage Grinder
. Other—Type of Building No.of persons _ Showers ( ), Cafeteria ( )
Other fixtures4qD
a
Design Flow(m' .r uired) gpd. Calculated design flow gpd Design flow provided god
Plan: Date 41 Number of sheets Revision Date 3
Title
Description of Soil(s) r res / t
i Soil Evaluator Form No. Name of Soil Evaluator� Date of Evaluation 1Z ,4Z zoo
DESCRIPTION O R FFEVAI S OR ALTERATIONS
± The undersigned agrees to install the above described Individual Sewage Disposal System in.accordance with the provisions of `
TITLE 5 and further agrees
snn/ot to,place the system in operation until a Certificate of Compliance has been issued by the Board`of Health.
Signed _�/' Gp Date
Inspections
- .'s.- Ili/�'ypr�✓^".,�dn"Z;Ty..w+i!�...�."^'M4'_wMr16.-w"!*'^' "�•+--..,....._. -
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FORM'1 APPI-1C`ATION�-F.O,RtDSC,P DEP APPROVED FORM 5/96 `
�.— r,— •.- ——,-..A——
No. !T � , THE COMMONWEALTH OF MASSACHUSETTS ; ` '' FEE �lJ�
�! .
° ✓� BOARD OF H.EALT\H
CERTIFICATE OF CO�MdPLIANCE
Description of Work: 2 Individual Component(s) 2 Complete System i
The undersigned hereby certify'tha, the Sewage Disposal System;Constructed( ),Repaired( ),'Upgraded(/),Abandoned( )
by: Chu ,! ��fDhI�N�.
at t� ! l J �60W,1 MAX
has been installed in accordance with the provisions of 310 C R 15.00 (Title 5) and the approved desi n lans/as-built
plans relating to applicationNo.��-D lZ dated 2 � ��� Approved Design Flow (gpd)
Installer
y vc• Designer: Inspector !7)',/L / y ®i at
The issuance of this certificate shall not be construed as a guarantee that he system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE *- DEP APPROVED FORM 5/96 i
I '
No. c) y- oSv THE COMMONWEALTH OF MASSACHUSETTS FEE /
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCT�I�Os'N-PERMIT
Permission is hereby granted.to Construct, ( ) Re air ( Upgrade (Y) Aba d n an individual sewage
disposal system at ` 1`t`7 1 VWf .�/ ,�� as described
in the application for Disposal System Construction Permit No. 2 o 17 �/ \ dated �assf F �'
Provided: Construction shall be completed within three years of the date of this p rmi A14ocal condi ions must be met.
Date a. 1 �� Board of Health / �. .
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W H06BS&WARREN TM PUBLISHERS- BOSTON
-A'R/14i2014/9CN ' 2.33 FM FAX No. P. 001
Town of Barnstable
Regulatory Services
y Richard V. Scali,Interim Director
1 4 RARN3CAMA '
�$ MAS& Public Health Division
man ►°, Thomas IMeK ,Director
300 Mab Street,Hyannis,TMA 02601
Office: 508-862—'1444 Fax: 508-790-6304
Wtaller&Desazner Certification Form
Date; A 14 101 Sewage Permit-4 D Assessor's Mapt�'arcel
Designer: stale : {
Address; Address: F
4�v 'Was issued a to instal a
�n permit.
(date) (installer)
septic system. at � ° J � ��4�'�� based on a design draw: by
(address)
dated
esigrzer)
rItify that the septic system referenced above was installed substantially according to
the design, which may include Wainer approved changes sect as lateral relocation of the
distribution boat and/or septic tank. Strip aut (if required) was inspected and the soils,
were found satisfactory.
i certify that the septic system referenced above was installed with majo-r. changes (i.e.
greater than 10'.lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State &Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in-co once with the terms of
the I\A approv - rters (if applicable) �H 7,,Z'-
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er s a i1Sv„
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gnatu e} (Affix Des/ p He,
PLEASIE RET'IJ N TO BARNSTABLE PU13LIC MALTII DMSION. CERTIFICATE
CE COTNtPLLANCE WILL NOT BE ISSULD 'UNTIL BOTR THIS FOR AND AS-
BUILT CARD ARE RECEIVED BY TBY� BARNSTABLE PUBLIC BEALLTH DIIVISION.
THAN3[
Q\Septic\Designer Ceititcation^orm Rev 8-14-13.doe
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Town of Barnstable P#
Department of Regulatory Services'`
Public Health Division Date 1 Z
65. 00 Main Street,Hyannis MA 02101
Date Scheduled � �;�� Time Fee Pd.
Soil Suitability Assessment or S e 's s t
Performed By:�1]2 1�?. fA 4 r/Vy� Witnessed By: i J
LOCATION&�'769NERAL INFORMATION
Location Address��E I y1 7�� ���Name -t�
1 UL ' LW�31�/
Assessor's Map/Parcel: ,V// Engineer's Name r y'
NEW CONSTRUCTION REPAIR Telephone# •.1 �J
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body It Possible Wet Area It Dfinking Water Well ft
Drainage Way ft Property Line ft Other ft
.SKETCH:(Street name,dimensions of lot,exact locations.of test holes&pert tests,locate wetlands in proximity to holes)
0
C
r
Patent material(geologic) Depth to Bedrockj '
103
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
r4�
Vl
Estimated Seasonal High Groundwater t
`• •DETERMINATION FOR SEASONAI;'HIGH-WATEIz!TABLE
. - Method
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level -Adj.factor -Adj.Groundwater Level_
PERCOLATION TEST Date " _ Tune
Observation
Hole# - Time at 9"
Depth of Pere Time at 6"
Start Pre-soak Time® Time(9"-6')
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) _
Original:Public Health Division Observation Hole Data To Be Completed on Back
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
f
DEEPOBSERVATION HOLE LOG ; Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
01
'1
DEEP„OBSERVATION.HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
DEEP`OBSERVATION HOLE LOG; `•:Hole# ''
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistencv.%Gravel
Flood Insurance Rate May:
Above 500 year flood boundary No Yes
Within 500 year boundary No�'Yes_
Within 100 year flood boundary No Yes_
Death of Naturally Occurrine Pervious Material
Does at least four feet of naturally occurring p i material exist in all areas observed throughout the
area proposed for the soil absorption system? 22
If not what is the depth f n Ily occurring pe 'ous aterial?
Certiflcation
I certify that on � �" (date)I have passed the soil evaluator examin lion approved by the
Department of Enviro ental Protection d that the above analysis Was perfo ed me consistent with
the r aired g,expertise an xp ' nee se ed in 310 CMR 15.017.
Signa Date
Q:\SEFnC)PERCFORM.DOC
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CO Postage $
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0 Certified Fee y�1 S /�/j
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Return Receipt Fee
O (Endorsement Required) �� Here,,
Restricted Delivery Fee C '8
p (Endorsement Required)rq
C3 Total Postage&Fees $
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o Pearl M. & Howard W.Williams, TRS
% Pearl M. Williams Trust
916 West Lake Holden Point
()rInndn Fl 32805
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cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
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` December 26,2013
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OF SHE?
Town of Barnstable Barnstable
Regulator.Services Department AD-Amm,caC
ft
saEttaSTABLE
MASS
Public Health Division
1639.
200.Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scaii,Interim Director
FAX: 508-790-6304 Thomas A.:McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851 1326
December 16,2013 '
Pearl M. & Howard W. Williams, TRS
%-Pearl M.Williams Trust _
916 West Lake Holden Point-
Orlando, FL 32805
1
- I
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 77-Milne'Road, Osterville, MA was last inspected on
10/25/2013 by Mark Polselli, a certified.septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the.following:
• Cesspool construction unsound; root infiltration causing blocks to bulge.
You are ordered to repair,or replace the septic system,within sixty(60) days from the
date you receive this notification.
'Failure.to repair/replace the septic.system:Within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thom cKean, R.S:, CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\77 Milne Rd Ost 2013.doc.
Parcel Detail http:Hissgl2/intranet/propdata/ParcelDetail.aspx?ID=7054
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Parcel Lookup
Parcel Info
Parcel
ID}118-021 Lot I LOTS 1 4&E-8
Pri
Location i77 MILNE ROAD i178
Frontage
Sec __. ___ _ __ __.__ __ Sec
Road' Frontage
Village iOSTERVILLE Fire 116-O-MM
District
Town sewer exists at this Road
address jNo Index
Asbuilt Septic Scan: Interactive �-
118021_1 Map l .
Owner Info
Co-
Owner IWILLIAMS, PEARL M&HOWARD W TRS1 Owner,PEARL M WILLIAMS TRUST
Streetl 916 W LAKE HOLDEN.PT Street2
City OR AL NDO State FL Zip 1'32805 Country i
Land Info
Acres Use ISingle Fam MDL-01 Zoning iRC Nghbd=0107
Topography Road l
Utilities I Location
A
Construction Info
Building 1 of 1
Year Roof __ ___. Ext r-.__.._-- __
950 Gable/Hip =ood Shingle,
Built' Struct Wall'
Living __.____.. Roof — AC
1452 Asp GIs/Cmp ;Central
Area` Cover Type -_�__.[-- Lnt� ��__ - Bed.
Style IRanch Wall'DrywallRooms Bedrooms
Into .�.__". _ Bath l __
Model{Residential Floor ICarpet Rooms'1 Full+ 1 H
______— Heat Total,_.
Grade Average ( Type JHot Water Rooms 17 Rooms
Stories, Story Heat- � ��Found `T ical
Fuel' ation yp
Gross
http:His sgl2/intranet/propdata/ParcelDetai1,aspx?ID=7054 12/2/2013
Commonwealth of Massachusetts
" Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address _.
ON ner ON ner's Name l
information is -/c,-//lie. �%/9 Qo��o�jr_ /O a,7- /_3
required for every "
page. C y/Town State Zip Code Date of in pact' n
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.
Mng outf rms A. General Information
filling out forms
on the rormuter,
use only the tab 1. Inspector: T o
key to move yourTl� � c/►
cursor-do not a✓4�'
use the return Name of Inspector
key,
VQ Company Name
Id
Company Address )/ ,ram )
City/Town State Zip Code
(:L,-
;go .
Telephone Nu er License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewagepisposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
N Title 5 (:310 CM R 16.000). The system:
❑ fPasses ❑..Conditionally Passes [Fails
❑ Needs Further Evaluation by the local Approving Authority;
} Q N
Inspect 's Sgnature Date
The ystem 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.
151m'Y13 Title 5 Officia Ins Pee bon Form Subsurface Sewage Disposal System-Pagel of17
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments;<'
Property Address
Av ner C W ner's Name /I__ /
information is os">u✓✓!6 e *" n/J� ao�b �O �72LIT
required for every /% 5
page. Cityfrown Stale.• Zip Code Date of Ins ection
B. Certification (cont) >
Inspection Summary: Checkr AB,C,D or E/ always corn plete 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;
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`wili pass inspection if it+is'structurally sound, not leaking and if a Certificate of
Compliance+ ndicating'that the tank is less than 20 years old is available,:
❑ Y ❑ N ❑ ND (Explain below); ,e
"
t51ns'��3 r Title5Of6ciallnspecbonFomSubsurfaceSewageDlsposel System.Page2oW
f
Commonwealth of Massachusetts
G Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
14
Property Address
Cw ner Cw ner's Name
information is ✓!i!`le p�6 SS
required for every _.._-
page, Cityrfown State Zip Code Date of Inspectich
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 D 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
t5 ns-Y13 TiUe 5 0f fici al Ins pec Lion f orm Su bsurf ace Sewag a Di sposal System•Pepe 3017
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
Property Address
0'N ner Cw ner's Name
information is O� ✓���/e �I�,r� Q���� lc,)L�1,13
required for every / '// Q
page. City/Town State Zip Code Date of Intpectio6
B. Certification (cost.)
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 Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.*A copy of the analysis must
be attached to this form. a
3. Other:
D) System Failure�riteria Applicable to All Systems:
You i cate "Yes" or."No" to each of the following for all inspections:
Yes NoPS�Vo
❑ 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
Lid due to an overloaded or clogged SAS or cesspool
❑ lL! Static liquid level'in the distribution box above outlet invert due to an overloaded
1--"or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Yz day flow
ISra•3r13 Title 5officiel Inspection Form Subsurface S"a Dlsposel System•Page 4of 17
I
Commonwealth of Massachusetts
. Q
Title 5 Official Inspection Form
a Subsurface Sewage Disposal Syste/m Form - Not for
/Voluntary Assessments.
lae
Property Address
ON ner Cw ner's Name
information is �� I„l��/ /� ✓�� ��� � �(� >/ i3
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont)
Yes No rZ
111
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ L� Any portion of the SAS, cesspool or privy is below high ground water elevation,
❑ [g/'— Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ER Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ED/ 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 collform bacteria indicates absent and the presence
of ammonta.-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
d 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, i.n 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.
5ns-3/13 Title 5Official Inspection Fam Subsuiace Sewage Disposal System-Page 5of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ug
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address-
Ow ner
Owner's Name
information is
required for every
page. Cityrrown State Zip Code fate of nspecC n
C. Checklist
Check if the following have been done: Yo'u must indicate "yes" or"no" as to each of the following:
Yes Nbf
❑ 1-l"Pumping information was provided by the owner, occupant, or Board of Health
❑ Lei —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?
n Was the site inspected for signs of break out? r
❑ Were_c311.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
;y^ sert-"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 Conditlons:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x #of bedrooms):
t5ins 3/13
Title 50tficiel Inspection Form Subsurface Sewage Disposal System.Page 6o117
Commonwealth of Massachusetts,
G v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
0N nem Owner's Name
Information Is �v!
required for every `e
page. City/rown State Zlp Code Date of l6spectioli
D. System Infor
Description:
Number of current residents:
Does residence have a garbage grinder? C] Yes EY Now
Is laundry on a separate sewage system? (Include laundry system Inspection �� ��
information in this report.) ❑ Yes (.� No
Laundry system inspected? ❑ Yes N�''��
Seasonal use? ❑ Yes L�1 No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes 92''NO ^ .
Last date of occupancy: L'f�
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(9pd)
Basis of design flow(seat s/persons/sq,ft„ eta),
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: e
t5m 3/13 Tide 501ficialimpecticn Form:SubstrfaceSevrageoisposei system•Page 7of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System For - Not for Voluntary Assessments
rp
Property Address 22
ON ner ON ner's Name Lz
information is
required for every
page. Cityrrown State Zip Code {late of I spection
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 1/A system by system operator under contract
❑. Tight tank. Attach a copy of the DEP approval,
❑ Other (describe):
U51ns-3113 Tiue 501ficid Inspacficn Form Subsu7ace Sewage olsposd System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form •
l ?� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address —
//� cil�
Ow ner Ow ner's Name I
information is
required for every (• v / �j'� ��2>_.,j �� oZ;jr' /�' -
page. W—Tow n State Zip Code Date of nspec-
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No �
Building Sewer (locate on site plan):
Depth below grade: --
feet
Material of construction:
❑ cast iron C40 PVC ❑ other(explain):
Distance from prvate,water supply well or suction line;
feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.);
Septic Tank (locate on site plan):
Depth below grade:
' feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
f
If tank is metal,-list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
l5na•3113 Tide 5 official Ins pectlmForm SubSLOWeSewege0ispossr Syslem Page Bo117
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form..- Not for Voluntary Assessments
//v1-292
Property Address
Ow ner ON ner's Name
information is 62Ay
required for every y b
page. OtyrTown State Zip Code Date of Indpectloff
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
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.):
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
tyre•?/13 7IOe50l6clel Iris peclJonForm Subsurlace SeNageDisposel System-Page 10of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form*
N1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Ow ner
ON ner's Name �J ✓vl/ J� ��Id
�' 1'
information is �/f //�� // �required forevery -� /`� / U��J J
page. City rrown State Zip Code Date of I spectio
D. System Information (cont)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, e�vidence,of leakage, etc,):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade,
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in worlang 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
5ns•N13 Tide 5Official Inspecdon Form Suburi ace Sewag e oisposal System•Pape 11 of 17
f
Commonwealth of Massachusetts
ugTitle 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Volunta Assessments 12
Property Address
Ow ner Ory ner's Name l
information is
required for every ✓V/Me // �ry 6 J_i elo '5
,+
page, City/Town State Zip Code Date of In ectio
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence"of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber (locate on site plan),
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on.site plan, excavation not required):
If SAS not located, explain why:
151ns-3113 Title 5 Official inspection Form Subsurface Sewage Disposal System-Page 12 o(17
l
Commonwealth of Massachusetts.
.
°
x Title 5 Official Inspectio°n F®rm
t
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Ow ner CW ner's Nameinformation is
required for every
page. City/Town Slate Zip Code - Date of In pectlorV
D. System Information (cont) n
Type;
❑ leaching pits number:
F,
❑ leaching chambers number; °
❑ leaching galleries number;
4, •
❑ leaching trenches number,"length;
❑ leaching fields
"' ° number, dimensions:'.
❑ overflow cesspool number.: .
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc,):
Cesspools (cesspool must be pumped as part of lnspecticn).(locate'on site plan)-
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer d/_
Depth of scum layer,
Dimensions of cesspool',.,
Materials of construction '
Indication of groundwater inflow ❑ Yes No
15iru•3/13 Title 5 Official Ism pec Um P orm Subsurf ace Sewage o(sposel System•Page 13 of 17
,
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F
Subsurface Sewage Disposal S
9 sp yste p Form Not for Voluntary Assessments
Property Address
ON ner ON ner's Name
Information is
required for every
page. Gty/Town State Zip Code Date of nspecti n
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-3/13
Title501ficlat Inspec don Ferm sumurfece sewage oisposal system.page 14 of 17
Commonwealth of Massachusetts
r
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System
�Form
'-Not for Voluntary Assessments
Property AddressOw ner /
ON ner's Name
Information is
required for every
page. Uy/Town State Zip Code Date Inspec lon�
D. System Information (cont.)
Sketch f Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at lea two permanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate
whe public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
t /J
/"V
• l Pow�
a1
t6ns y13 Tltle50f%ja'InspecUonForm SUDSLfface SewageDlsposal Systsm-Page 16 of 17
Commonwealth of Massachusetts '
Title 5 Official Inspection Form •
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°? � /11//
Property Address
(A//'
iInformation is Ov ner's Name ✓r/l� j /c7A
required for every �l 3
page. City/Town State Zip Code Date of I pecvon
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the"high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting prop ert&bs e r vat ion hole within 150 feet of SAS)
❑ Checked with local and 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
Before filing this Inspection Report, please see Report Completeness Checklist on next page,
t5ins•3113 Tide50fAcial InspecbonForm Subsurface Sewageoisposel System•Page 16 of 17
t'—
Commonwealth of Massachusetts
Title 5 Official' lnspectio„n� Forrn
Subsurface Sewage Disposal System Form,Y-Not for Voluntary Assessments
h
Property Address
info rmation is ner Owner's Name
required for every
page. City f Tow n State Zip Code Date of Inspectiori
E. Report Completeness Checklist.
Inspection Summary: A,nB, C, D, or E checked
In ectio -Summary D(System Failure Criteria Applicable to All Systems)'completed `
tem Information— Estimated depth ~ A
pt to high.groundwater .
❑ Sketch of Sewage Disposal'System either drawri on page 15 or attached in separate file
t3ins•y13 TItl85Official Ins pectlonF.crm SubsuYace S"eDlspossl system•089e,17 of 17
i
i
I
I
ASSESSORS MAP : TEST HOLE LOGS
PARCEL : Z/ 1) The installation shall cori,j.:, witli Title V and 'fowu of g Board ol:
FLOOD ZONE: SO I L EVALUATOR : 4Yd
Q � ��- �f�G� yN [leallh Regulations. '
2) The installer shall verify the location of utilities, sewer inverts and septic
WITNESS : �'.I�'r+/�j /p
Y` REFERENCE : � (, C/ / >.� DATE : components prior to installation and setting base elevations.
—_- z Z�3
PERCOLATION RATE: -G Zu'l/ ' - � 3) All gravity septic piping to be 4 inch Sch 40 PVC at l/8" per loot. "l �e u-st
/
two feet out of the d-box to the icaching shall be level.
4) This plan is not to be utilized for property line deterniination nor any other
l -- - -- --
TH- I ! TH-2 purpose other than the proposed system installation.
`, � /�c5 "�-�-' � �►9vt� ,�'r/�/Y� 5) All septic components must meet Title V specifications.
yL� I 6) Parking sliall not be constructed over I I 10 septic components.
7) The property is bounded by property corners and property lines.
8) The property owner shall review design considerations to approve of total
L 0 CA T I 0 !� �► Vv 'e`�' t�3 design flow and number of bedroorns to be considered for design. Receipt
N MAP —
1 of payment for (lie plan and installation based on the plan shall be deemed
f approval of the design flow by the owner.
9) 'file existing leaching or cesspools sliall be pumped and filled with material
ID pQ7 t? ��j y��,71� per Title V abandonment procedures. Those within the proposed SAS shall
8�d/ l be removed along with contaminated soil and replaced with clean sand per
a , d Title V specs.
0 �1 10)System components to be 10 feet from water line. Sewer lines crossing the
40 b D 6 water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if
✓ Zz i applicable. The proposed SAS is being installed below the water service
line. "file line is to be sleeved as aforementioned and maintained in place.
� ) _— S E P T 1 C S Y S T E M I D E S ! G N 11) If a garbage gander exists it is to be removed and is the responsibility of the
owner to ensure such.
�'\ �� 12)'I'he installer is to take caution in excavation around the gas line if such
31 FLOW ESTIMATE i exists.
t /r location, quantity and elevation of the sewer
7 //� -� 13) the installer shall verify the lacatror , y y
f BEDROOMS AT GAL/DAY/BEDROOM .SAL/DAY lines exiting the dwelling prior to the installation.
14)This plan is representative only that a system can fit on a property meeting
SEPTIC TANK Title V requirements.
.GAL/DAY x 2 DAYS - 46D GAL
0
000 _ ! ° \c30 USE GALLON SEPTIC TANK
0
SOIL ABSORPTION SYSTEM---------
l2wl ! ? = ` - _°� , 1 -�;r�.�-�, ,; -ram . j H or
SIDE AREA: -t�Z, G'� 3 137 MASON �1'
BOTTOM AREA: , j l2 )S 7 �13 NO.toss a GY
SYSTEM , SECTION
IDS
N ,
ofwit,
O
b_-` C.111g -D-BOX
qJ 2 3
GAL 2- �406t�
l vSEPTIC TANK , —
/ 7 ,
791
SITE AND SEWAGE PLAN
0 LOCATION :
1+ , li-2v V' o PREPARED FOR :L I
1
SCALE: /
o � I
t DAV I D B . MASON,RS DATE: 11512DIq
DBC ENVIRONMENTAL DESIGNS
EAST SANDWICH . MA
DATE HEALTH AGENT ( S08 ) 833- 2177
't