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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEI �D
APR 2 7 2003
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 25 Picasso Place
OsterMle, MA 02655
Owner's Name: Ransom Reynolds
Owner's Address: 147 Parker Road
Framingham, MA 01702
Date of Inspection: March 13, 2003
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford Map: 145
Mailing Address: P.O. Box 49_ Parcel: 081
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs her Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: March 14, 2003
The system inspector shall sub t 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Picasso Place
Osterville, AM
Owner: Ransom Reynolds
Date of Inspection: March 13,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CM ;
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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Picasso Place
Osterville, AM
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluatiori 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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply. '
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Picasso Place
Osterville, MA
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/s day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone I of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen,is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes:':or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 25 Picasso Place
Osterville, MA
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week..period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_ 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(3)(b)].
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 25 Picasso Place
Osterville, M4
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a '
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the.inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
New pit added on 7110195-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Picasso Place
Osterville. kM
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 6"
Material of construction: ✓ concrete metal fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: - Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
N
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Picasso Place
Osterville, MA
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
TIGHT or HOLDING TANK: None (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: allons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan) ,
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Picasso Place
Osterville, MA
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
One leach pit 04)had approx. Y of water on the bottom. The cover was 15"below grade. The bottom to grade was 8. The
newer pit 05)was dry. The scum line was 6"up from the bottom. There were no signs of failure. The bottom to grade was 96".
The cover was 15"below grade
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
vf Page 10 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Picasso Place
Osterville, MA'
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
Map: 145
Parcel: 081
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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30 3o
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30 69
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Picasso Place
Osterville, MA
Owner: Ransom Reynolds
Date of Inspection: March 13, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40 +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
40'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
No. Fee y®
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYicatiou for Milpoe;ai *pgtem Cow5truction Permit
Application is hereby made for a Permit to Construct( )or Repair( V an On-site Sewage Disposal System at:
Location Address or Lot No. Z✓ IVIca 55Q���e Owner's Name,Address and Tel No.
Assessor's Mag/Parcel
0,5,-e/'ville //cear-l��sr
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms `� Garbage Grinder
Other Type of Building_ P.S/c% vol�lGe No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Zza gallons per day. Calculated daily flow '53e gallons.
Plan Date B"—L�— 3 Number of sheets Z Revision Date
Title
Description of Soil
Nature of Repgirs or Alterations(Answer when applicable),jr1614 11
12 14 !!!�e�e��
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued this B of alth. / /
Signed Date >'<10l e�
Application Approved by Date -7—/0 1 96
.Application Disapproved for the following reasons
Permit No. / G o �� Date Issued 7 y �'
yv
No. ; Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH.DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
1
ZippYication for Zigool *p6tem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( /an On-site Sewage Disposal System at:
Location Address or Lot No. C7 ��QG� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
�w
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
' Type of Building: III
Dwelling No.of Bedrooms 3 Garbage Grinder(19 1
1�
Other Type of Building i.&4�a No.of Persons Showers( ) Cafeteria( )
Other Fixtures i
1
Design Flow 1//i gallons per day. Calculated daily flow gallons.
Plan Date R°-7_. - 9?3 Number of sheets 2 Revision Date
i
Title
"
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) z1.5 ys_'&
t
Date last inspected:
Agreement: ' ,,
The undersigned agrees to ensure the construction and maintenance of de afore<described on-site sewage disposal system 1;1
in accordance with the provisions of Title 5 of the Environmental Code and not to pla e system in operation until a Certifi-
cate of Compliance has been issued b this Board of alth. / 1I
Signed - Date ;!!!f' 1
Application Approved by Date 7`/O -
Application Disapproved for the following reasons
Permit No. 9 L �� Date Issued 7 /
v- Q�
————— ———————————— ——————————————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on
by Installer �/?d
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Constructio _o t No. 9G- � I eF dated ,7 - /D -5� 4- .
Date !7 < Inspecto
THE ISSUANCE'OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TIAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.----------------------- - ---------------
Ij
i
No. -3 IF
( Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
33i5poof bpotem Cow6tructton Permit
Permission is hereby granted to dl7fUL e / Ce o/ 5,7
to construct( )repair( Vfan On-site Sewage System located at No.# Z /C415,0e' lfl'G�
. - - street
and as described in the above Application for Disposal System Construction Permit. (/�G �'/� 7 /D
No. Date
4
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
Date: ? ' l d "- g Approved by
Board o�Walth
i
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCHON PLANS)
(, kokv-r,,74A� � ^ereby certify that the application for disposal works
construction permit signed by me dated 711elM , concerning the
property located at Z %cSSc� hC p yei^l�i �meets all of the
following criteria: .
T ere arc no wetlands within 300 feet-o rt a proposed septic system
T cre arc no private wells within 1 So rcct of the proposed septic system .
he observed groundn•ater table is 14 rect or greater below the bottom of the leaching racility .
There is no increase In(low and/or change In use proposed
4/ There are no variances requested or needed.
SIGNED: DATE: Z11, lee-5, .
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan or the proposed system. Also irthe licensedlnstaller posesses a certilkd plot plan,
this plan should be submittcdl.
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- N3
BORTOLOTTI CONSTRUCTION INC. 1996
765 WAKEBY ROAD,MARSTONS MILLS,MA 02649
508-771-9399 508428-8926 FAX: 508428-9399 �f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ALSESSORS MAP NO* -
CERTIFICATION
Property Address: 5� 0 r���Q� PARCEL WO'
Date of Inspection: Inspector's Name:
ees N e and Address: pl �� �- oc
CERTOCATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on mY training and experience in the proper function and maintenance of on-site sewage
disposal systems. The System:
Passes
Conditionally Passes
--,L Needs Further Ev don By ie ocal Aproving Authority
Y Fails
Inspector's Signature: Date:-
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30):days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY!
A)SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
not.determined",explain why not.
The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
.I _
r
v
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
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 I5NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspoolo privy
r ri is within 50 Feet of a surface water
P
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 FUNCTION-
ING 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
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for colifonn
that the well is free fro
m llution from
bacteria and volatile organic compounds indicatesPo
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)S STEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
sho contacted to determine what will be necessary to correct the failure.
V Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
D'scharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS.or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
r .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high roundwater
vY gro
undwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply,
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone 11 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
_kLPumping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
P-As-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
✓All system components,excluding the Soil Absorption System,have been located on site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees,material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum. #
v The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
'4 -3-
h
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
Th facility owner(and occupants, if different from owner were provided with information on
e ac ty o (a p )
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RYSMENTIALev
Design Flow: gallons Number of Bedrooms:_ Numbcr of Current Residents:
Garbage Grinder: Laundry Connected'I'o Syslem: � Seasonal Use:
Water Meter Readings, ifavailable:
Last Date of Occupancy:(/A/Xt�s5
COMMERCIAUINDUSTRIAL: AID
Type Establishment:
of Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informati
System Pumped as part of inspection: If ye ,volume pumped: gallons
Reason for pumping:
TYPE F SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
AP OXIMATE AGE of all components,date installed(if nown)and source of information:
Sewage odors ditected hen arriving at the she:
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Ma terial of Construction: I.,concrete metal . FRP Other
(explain) —
Dimisions: Sludge Depth: Scum Thickness: 6
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to tlet invert, ctural integrity,evide a of leakage,etc.) >< /��
f
G
GREASE TRAP:
Depth Below Grader Material of Construction: concrete metal FRP Other
(explain) — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK: O
Depth Below Grade: Material of Construction:—concrete_metal_FRP Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments: (note' el and distributi n is equal evidence of solids c o r,evidence of leakage into
or out of box,etc. , �
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
, A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cowinued)
SOIL ABSORPTION SYSTEM(SAS): l�
to on site plan, if possible;excavation not required,but may be approximated b non-intrusive
(� p � Im eq Y pp Y
methods) If not determined to be present,explain:
Type:
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil, signs hydrau 'c failur level of ndin rti n A'gen,
etc.) GZ ,7
T ~
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Material of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6 -
I
N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benclunarks.
Locate all wells within 100 Feet.
i
y�
DEPTH TO GROUNDWATER: '
Depth to groundwater: 2 .Z Feel
Method of Determination or Approxinotion: /2r,1'ik�Q G�1``i'®�� A/-5
T
-7-
LOCATION LoT �0 4 "� &0.
....
`y
VILLAGE OS-MQ 4i LL9 DATE 07 IT- SS
APPLICANT, kz E EMra60Z.,.cooQ.P. FEE
TELEPHONE N0.1'f -3(,��,(Non-refundable
ADDRESS cz-w E QVt L..�s _..._�......_.._._.......-,.,--.
ENGINEER ELDD� N 1AiEQ�1�lb TELEPHONE NO. 135,• �.14
DATE SCHEDULED' JVL+( . l.G h't'oE
Applicant's signature.
SOIL LOG
SUB-DIVISION NAME ft , 0- 01%7- 1LL z. " •'DATE - .2., 113 TIME q ��
EXPANSION AREA: YES ✓ NO J®H t.l Q. . e L LI S ENGINEER
TOWN WATER✓ PRIVATE WELL ja4 N J A GO P. 1 BOARD OF HEALTH
l SC2 L L EXCAVATOR
SKETCH: (Street .name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes )
NOTES:
h
Les
PERCOLATION RATE: < M iU l e N C to
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
3 3
4 �, 4
5 5
. 7 M� 7
I � � S � 8
9 9
1-0 41/ 10
11 11 ,
12 12 ,
13 13
14 14
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS
LEACHING TRENCHES
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER. ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN AXI R ANQ ELTURNED 10 BOARD OF HEALTH '
I
COPY! RETAINED BY APPLICANT