Loading...
HomeMy WebLinkAbout0109 WINTERGREEN CIRCLE - Health 109 Wintergreen Circle, Osterville i y a 3 F u o t� a I s cam, Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 109 Wintergreen Cir Property Address Maureen SudbeyI; Owner Owner's Name/ information is Osterville ✓ Ma. 02655 6-30-20 required for every — page. City/Town State Zip Code Date of Inspection r; Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites path Company Address South Yarmouth Ma. _ 02664 Ale City/Town State Zip Code 508-477-8877 _S114430 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 below,is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes ,N OF IMA�����i4 �. 2. ❑ Conditionally Passes MICHAEL `yN' 3. ❑ Needs Further Evaluation by the Local Approving Authority __`o: SEARS No.SI14430 03 4. ❑ Fails ohn.- �, 6-30-20 Inspector's Sj nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority,(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies-sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Wintergreen Cir u g Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 109 Wintergreen Cir 9 Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged.SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes-if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10..000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form '- II; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Wintergreen Cir u— Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on-the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form }I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ �!% 109 Wintergreen Cir V Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Cir v Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No t Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 6-30-2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of IS c Commonwealth of Massachusetts �n Title 5 Official Inspection Form �ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 . 6-30-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 27" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line:• feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. City/Town State Zip Code Date of Inspection D. System Information,(cont.) I 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 24 2" Scum thickness 8 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Sludge gudge, tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with both covers at 2" below grade, tee in baffle out t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « � 109 Wintergreen Cir V� Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 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): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is 16x16 with 1 outlet pipe cover is at 30" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I c Commonwealth of Massachusetts r� _ Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �C � 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1- 1000ga1 ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form �- �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma, 02655 6-30-20 page. CitylTown 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:): SAS is a 1000 gal pit at 5' below grade with cover at 4" below grade, 1' of water in pit no sign of failure - 12. Cesspools (cesspool mustbe pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc Frev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 109 Wintergreen Cir u Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655' 6-30-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts �� _ : :• Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 109 Wintergreen Cir u- Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 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 i O O I � AI •- "' a— igb 3- a•7ow q- 3 M t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 I . Commonwealth of Massachusetts �w Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Wintergreen Cir u� Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14' 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 84 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: Plan h I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 r - Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Wintergreen Cir Property Address Maureen Sudbey Owner Owner's Name information is required for every Osterville Ma. 02655 6-30-20 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 ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated.depth to high groundwater included I� I 11 ", o)n of SAS 1y 3P Nv c7�.'`0✓H�w9'�'u' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No................ ..."L - Fus..... ................. A— THE COM'M'CNWEALTH OF MASSACHUSETTS i BOAR® OF HEALTH pGtl!'1.......................OF...... .....h.�f x_ .L-- ApplirFation' for UhiposFal Works Toustrnrtiun Frrmit �a A lication is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: - ..... - d5T v u ----.A ------------------------ Location-Address or Lot nstaller / Address Type of Building Size Lot_ ZAM.......Sq. feet U Dwelling—No. of Bedrooms........... .............. .. .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P-4 Other fi tures ...------•-------------------•-----•-•------------ --. ----- ------------------••-•.-•----- W Design Flow_...._...._____................:......gallons per person per day. Total daily flow.._..._.__ _�1_�........_..._._....gallons. WSeptic Tank—Liquid ca.pacity�!!f/!f__-gallons Length"TP..__. Width................ Diameter_............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.................... Diameter......I1?........ Depth below inlet......&_......... Total leaching area l'O.sq. ft. Z Other Distribution box (✓) Dosing tank ( ) r a Percolation Test Results Performed by..0. `_Wit-.. ��G t l�G:..._. Date.....1.v. Z_ _� ,a Test Pit No. 1...L�..minutes per inch Depth of Test Pit.-,-.1.4.......... Depth to ground water_.Ijb_W `C (� Test Pit No. 2................minutes per .inch Depth of Test Pit.................... Depth to ground water........................ ---------••-•-------------••----•--.--..-----....._....:. ----------------•---•- -------- -- O Description of Soil ... ZU5�1 L'-f--�-���dd ` 1�� _ -.. (�� x -------•-•-•-------•--- / V •••-------------------------------------••-•---•--...---------------------------------------------•-•••-•--------•--------------------------------------•----•---------------------......---------•----- 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 TITL 1Z 5 of the State Sanitary Code— he de ned further agrees not to place the system operation until a Certificate of Compliance has be ' s e y e d of health. Sied.. /�.`... . . . ..... . .............................................. /�-- -- . •- .... Da I Application Approved BY................ -A-----• •---------- �... �.... Date Application Disapproved for the following reason .----•----••-----------------------------•--------------•--------------•-----------...---- ...................... ..............•--•--•.....---•--------------•------------------•-•--••-----•--------•-----------.....-•---------------------------•------------------------------•-•---------------------•••------------ Date PermitNo......................................................... Issued....................................................... { Date No.._........ "_✓. ..� "! ;� Fss.....:r.`.............._ THE COMMONWEALTH OF MASSACHUSETTS �;yw, •1,/`! ' BOARD OF HEALTH .........OF...... h. Appliraiion for Disposal Voiks Tonstratr#iun Prrmit Application is hereby made for a Permit to Construct (/ or Repair ( ) an Individual Sewage Disposal System at: ..............L ............................-� .�..I .. ......................... Location.Address or Lot o. �^ jr• -1?7 f< ivi��.:s.:! -�� �'�.G�._._. � ��2 .....i �_/4. !ti1..... �'-�....................... Owner t _ .._ Add eS .................................... _ . .. ' 1...7 •r?l, ........1 j ...� '•!.. � - � Installer � •Address Type of Building y� Size Lot.Z : ita••------Sq. feet U oms.__.._._..1__............................Expansion Attic ( ) Garbage Grinder Dwelling—No. of Bedro ( ) 44 Other—Type of Building ............................ No. of persons:...__.._..,............... Showers ( ) — Cafeteria ( ) dOther fyctures - -` �,�fv = W Design Flow.......... ..................:--:-----_gallons per person per'day. Total daily flow__.__........_......._........_...._.._....gallons. R: Septic Tank—Liquid capacity)llGl.__gallons Length` 1 ...... Width................ Diameter_____________._.bepth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching larea...:........__......sq. ft. Seepage Pit No------I.............. Diameter-----1.42......... Depth below inlet..... ...... Total leaching reaZ�?7c. sq. ft. Z Other Distribution box (✓) Dosing tank ( ) `` /. ~ .- `., . 1 -- Date-----F ..f Z• - ------. Percolation Test Results Performed by 1 _ =vL , h� - Test Pit No. ---minutes per inch Depth of Test Pit___ Depth-to ground water.�L._L�AT� fs, Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth't ground water._.__.._.__..._....._... •--•---------- ------------------------------•----------------....--------------•-••......----••. O Description of Soil-----... ..2 -1''......................................1 j !` � _ � !_ .. ............................. /� E f -- ----•-.... x ..V = = ............................... 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 TITS 5 of the State Sanitary Code— he nd signed further agrees not to place the system ip operation until a Certificate of Compliance has b issue by e • rd of health. �� _✓` 'Da r 1l ApplicationApproved By............ ......----•=.... .... •---•------------------------- !1 .. .................. Date Application Disapproved for the following reason ................................................................................................................ ......................................................................•----------............-------••---•-••--••••---•-••-•----••--------•-----•-••-••---•-----------•--------•---•--•-----•. Date PermitNo.......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARDr OF HEALTH_- d .t.� f...............OF..; s:�..,t'✓ '`.�` fj1i ................ TnrtifirFate of TontpliFantr THIS TO !R`T/IFYhat the Inwidual Sewage DisposalSystem constructed l"P) or Repaired ( ) j/ + r v Installer p j" has been installed in accordance with the rovision's of TIT r' 5 of The tate SanitaryCode as described in the application for Disposal Works Construction Permit No...... � . dated .............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS �....�- BQARD F HEALT�I, �:► L, .11 ~' ..................OF..... :. ...�, ..... e--/.. ................ r� FEE.....:f.............. or Tootr , yrrMit__,_ �io loal bPermission is hereb ranted....... .. ✓ to Constructor Repair_,C,. ) an Individual Sewage Disposal System at No. �/P4{'.. ... ✓f!�.1__.:1��'' ' ' ._: s! .Ls l"'�f`= ---------------•------•--•--•-- c.-• / ---'- 7-._'--- Street..._,:.-- - as shown on the application for Disposal Works Construction Permit No..................... ............... Dated....:..................................... Board of Health DATE. 8b_ . _..._. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS {I N i S/TE PL A lV SHEET,7 OF? SCALE: 'l Nr z ; i v 9_ N �lk' V WILLIAIrt No, .19771 j �0.O© 7 FOR REGISTERED LAND SURVEYOR W I N T k--7-6 ZONE D O`�'C� V tLLIE. M -000. PLAN REF. DATE SEN�H MARK DATUM 'WM. M. WARWICK 6 ASSOC., INC. DOMESTIC WATER SOURCE"C" w�T BOX 801 "NOR TH, FAQ.MOUTH ' FLOOD ZONE. or.► 6-1�. -�..� x . .. MASS. 02536 .- (617) 56,E-.2656 Q L F "CHING 041,511V SECTION NOT.TO SCALE Sh cc.vl 2 ®f .Z 24"C.l.UH COVER f.AFrlH F/LL 8R/CK AND MORTAR C90RSES'A R£0'0. TO 8RING I i4, COVER TO GRADE 4 8 FLOW i /NL ET� T- �L_ _ _ _: ,: ?-� TO r�+ GNASHED PEASTON£ FREE. OF IRONS, P/PE r� I :• , : F/N£S ANo DUSr /N PLACE �: V �.•...•I,• '. it , • • • , ,� r,' F . , •' (�� OPENING WITH 4%g" �4: To I! WASHED CRI/SHED S/ONE..FREf OF• .,7 �- OUTER DIAMETER IRONS, FINES AND o(ISr IN PLACE AN0 I314"INSIDE I DIAMETER 1', CONCRETE TO. BE 4000 PSI 28 DAYS • 2. REINFORCED WITH 6"x 6" N0; 6 GA. W.W.M. •' ' 3. 2 AND 4' SECTIONS ARE AVAILABLE FOR GREATER DEPTH REQUIREMENTS 4,0.. ^—�'----6ro" --I---�� --� 4• NUMBER OF PITS REQUIRED a_015' nslN Io NOTE: EXCAVATE TO ELEVATION 0 OR ' EffECT/VE(Nor r0 EXCEED 3 TiNEsoIAA/ETER EFREcr/VE DEPrHI LOWER AS REQUIRED TO REMOVE ALL ---��- WATER 7481E— LOAM AND CLAY BENEATH PIT, REPLACE " EXCAVATED MATERIAL WITH CLEAN TYP/CAL PROF/LE GRAVEL TO DESIGNED GRADE.. IB"STD. LT. WG7. C.I.MN COVEIP yo,y •, o,v 49 �S,v 4"8/T,FIBER P/Pf 4 C/.PIPC r^ " T/GMT JOINT OUTLET LEVEL ' DWELLING FLOW LINE TO FIRST JOINT TEE }} 'S (0�1 i Op Igo o 9� p , -+ � 11000 0 0: 1 1 ii • STD, PRECAST CONC. �6•�l$ lsr. Box ro BE �, 1 1 10 00 00 0 1 , W0644.SEPTIC TAN Q----- 11 1 0 0 O 00 do INSTALLED ON LEVEL, STABLE BASE ii1000 0011 � i S£PT/C 144, 70 8E 1 000 0 0 1 I.� INSTALL LE6!PG, . I it 100 O 0 1 1 STABLE BASE:' i 1 1 0 0 � 11too 0011 � � LEACHING BASIN 1 e 0 O 0 0 0 I , , 9A,SE TO B£LEVEL 1 0 1 b 1 01 r SO/L AND PERC. DATA Gz 11 TEST P,IT NO, TEST PIT NO. 2 PERC, RATE .._._._. MIN. /IN 0 0'� Ti P15 TEST BY SZvcE' 44>-L.t� Z'< ' . WITNESSED. BY: o N �►to p �6 NIM �p TEST PIT GR. EL. DATE: n a o 1�1► �t,�� NO 4 fz/'i D.WAc 2. :X,p DESIGN DATA 6,FNfRA4 `NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL Now SEPTIC TANK, DIST, BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL.3 - GPD. _.PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK loop GAL. AIL:-.SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREAL'2 GAL./SQ.FT. MINIMUM REQUIREMENT$ FOR THE SUBSURFACE DISPOSAL , OF BOTTOM AREA 1­2' GAL./SQ;FT. : ' SANITARY. SEWAGE EFFECTIVE ON' JULY 11 1977. LEACHING REQUIRED 129'1 SQ•FT. ANY -CHANGES TO THIS PLAN MUST BE APPROVED BY THE-BOARD ACTUAL LEACHING AREA OF, HEALTH, �_. O.FT. AT-COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES I/4u / FT, UNLESS INDICATED OTHERWISE, •� � ;„s 9;�� SEr' A6C DISPOSAL SYSTEM o MARTIN y� E. FOR.- L• C�IL -�t�L-aic�5 . w.0 MORAPd (2 C CSC #23417 IsrE- SCALE AS IND/CArC0 DATE I t il 1�7 WX N. WARWICK s9 ASSOC., INC. BOX 801 NORTH fA.4 AvuTN MASS, 0,0056 (6171 165-Z658 PROFESSIONAL ENGINEER 777 . T Commonwealth of Massachusetts 17 - Title 5 Official Inspection orm -- � _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessment ^M 109 Wintergreen Circle Osterville MA 02655 M,a Property Address ' Lisa Federico,,,, Owner Owner's NameR'. +� information is x. required for every we-stowQ 1� I�I�I MA 02493 July 1, 2015 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in'any way. Please see completeness checklist at the end of the form. Important:out forms n A. General Information �, filling out forms I O r on the computer, I use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason ray Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number 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 sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 'w"`�"`.- Ukf �,-- io- July 2, 2015 Inspector's Signature. Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under h the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1 2015 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. Change or increase in use may result in hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information re Y Weston MA 02493 Jul 1 2015 required for every , page. City/Town State Zip Code Date of Inspection 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 ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1, 2015 required for every Y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1, 2015 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1 2015 required for every Y page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? �I ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1 2015 required for every Y page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 I Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (9P ))� Detail: 2013; 44,000 gallons and 2014; 36,000 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1 2015 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Typical Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1 2015 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 47" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour 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.): Effluent level with outlet invert. Precast tee in place appears in operable condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Ill Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1, 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is-copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1, 2015 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Unknown 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.): Could not locate distribution box. Observed leaching pit since could not locate . 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1, 2015 required for every _ Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Ij Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 6' leach pit at a depth of 5'. Riser in place only to within 33" of grade. This is why d-box could not be located due to depth. No signs of hydraulic failure or pondin . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M , 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Y Weston MA 02493 Jul 1 2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1, 2015 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 w Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 109 Wintergreen Circle Osterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 Jul 1 2015 required for every Y page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 109 Wintergreen Circle Cisterville MA 02655 Property Address Lisa Federico Owner Owner's Name information is Weston MA 02493 July 1 2015 required for every , page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface •Sewage Disposal System Page 17 of 17 P Y 9 t Commonweafth of mossocHusetis Executive Office of Environmental Affairs ---- --- Department of - RECEIVE Environmental Protection MAY William F.weld HEALnGovernor TOWN OF BA Trudy Coxe - Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:.I G9(�" i i`t i e e-C>:'ae N +c-��._ 0`.Si�-eV'jkddress of Owner: tFkA Date of Inspection: Lt- z-1 (If different) C- ° e Name of Inspecto .,� � A Company Name, Address anAelephone Number: _ CERTIFICATION STATEMENT 1 cenik-that I have personally inspected the sewage disposal system at this.address,and.that the..information-wported.,be.l.oa+:.,is.true, accurate and complete as of the time of inspection, The inspection was performed based on..my training and-experience in the proper function and maintenance of on-site sewage disposal systems. The system: `' Passes _ Conditionally Passes _ Needs f urthei Lvaluatiun By CA, lucml Approving Authurity Fails r'1 Date: tt .3D s' Inspector's Signature:< - - The S%sem Inspector shall submil a copy of this ins e7ion report to the Appioving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design fluw of 10,000 gpd of greater, the inspector and the system uwnet shall submit the repor. to the appropria!e regional office of the Department of Environmental Protection. The original should be sen: IL' inc syste•m owner anti copiv Beni to the buyer, if applicable and th( approving INSPECTION SUMMARY: ' Check A, B, C, or D: A) SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 31.0 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 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, cracked, structurally unsound, shows substantial infiltration or exfillralion, 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 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone (617).292-6500 �, Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address:, 0 W1(� jCGrGj<- Gcv� Owner: t=cktA e,>- Date of Inspection: .. -. _._.._.,... __...-_.._.... BJ SYSTEM CONDITIONALLY PASSES (continued) �) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced 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'11EALTId DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECI ]HE PUBLIC HEALTH AND SAFETY AND 11-IL ENVIRONMENT. _ Cesspool or privy is-withih 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 ENVIR0N,%tENT: _ the wstem hay a sepuc tank anu soli ausurptiun system and iD wiliiiu iO3 icci lu a supN!r G, a surface water supply. _ The systeni ha, a septic ►ant, and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100.feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that.facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5. ppm• D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system componen►:due to an overloaded or clogged SAS or cesspool. Discharge orponding of"effluent to the surface of the ground or surface waters_due to an overloaded or clogged SAS or cesspool. r (revised 6/i5/55) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address: (U"l wlr �r• v,, �,v..C,r , O�i k'i Owner: Date of Inspection• a 30"1.7 D] SYSTEM FAILS (continued): a.5tatic_liq.u.id.level-in,_the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped N 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. 4" ��T/ Any portion of a cesspool or privy is within a Zone I of a public well. _I 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 large systems in addition to the criteria above: . .,. The design flogs of 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 A ithin 200 feet of a tributary to a surface drinking water supply the system is located in­a nitrogen*.sensitive area (Interim Wellhead Protection Area_(IWPA) or a mapped Zone II of a public water suppiy 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. r' i P (revised 8/15/95;) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: k Opt Owner: P_eA_)W- Date of Inspection: Check if the following have been done: = PU mping iriforiration was"reiauested of the owner, occupant, and Board of Health: — None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /' As built plans have been obtained and examined: Note if they are not,available with N/A. _�: (he facility or dwelling was inspected for signs of sewage back-up. The system does not receive nor'-sanitary or industrial waste flow (ffhe site was inspected for signs of breakout. �ll system components, excluding the Soil Absorption System, have been located on the site. ' I _L'Ihe septic tank manholes were uncovered, opened, and! the interior of the septic tank was.inspected for condition of baffles or tees,,material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption"System on the site has been determined based on existing information or approximated by nun-intrusive methods. _ihE fd�i�i;� G.•,:.!- ;,••.;! u:<�;i)1••.ii, if G�:��P.'!'^r (•n�- ov:ner'. were provided with information on the proper maintenance of Sub- Surface Disposal System. i (revised 8/15/95) 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `SYSTEM INFORMATION Property Address: I O� Owner: IFO" Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: .g I�lons Number of bedrooms: —� Number of current residents:C—� Garbage grinder (yes or no):z e Laundry connected to system (yes or no).V Seasonal use (yes or no): 14 Water meter readings, if available: N 1 -..-Last.date of occupancy:_ -COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Neater meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupanq. GENERAL INFORMATION PUMPING RECORDS and source of information: y. 30 �? System pumped as pan of inspection: (yes or no)_ - - If yes, volume pomned gallons Reason for.pumping: - TYPE OF TEM. Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: /L'7J Sewage odors detected when arriving at the site: (yes or no3 Y _ 5 (revised 8/45/95) SUBSY$F.ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (06( U%�tit�.—C', �' r �) 1 Owner: i::__01. Ie.i- - Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grader � Material of construction: —concrete _metal _FRP —other(explain) Dimensions: Y Sludge depth: 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: , j. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid l9yel in riplation to outlet invert, structural inte ity, evidence of leakage, etc.) x i'�t�r��r��`� c;_VG L_ GREASE 1RAP;_0 (locate on site plan) I Depth below grade: Material of construction: _concrete _metal _FRP other(explain) Dimensions: Scum thicknes;. Distance from top of scum to top of outlet tee or baffle: Distance from bottom M crlim v, tlntlnr^ of oteip! tPe o' t)allle' - Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM --PART C. ..A.. a._,_.. _ SYSTEM INFORMATION (continued),. ' Property Address:(QC� tt l«Q-,.�r�c <•—�C �r•�.�� �c,,'f, **k-.Owner: e-.— Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) 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.) I DISTRIBUTION BOX: (locate on site plan` Depth of liquid level above outlet invert: Comments: mote li ievei anu distriuu('u"� c tyuat, e'.66-Icc 0; sui.0 C'i;I l(:i, evidence of leakage into or out of bo\, etc.) PUMP CHAMBER:( (locate on site plan). Pumps in working order.(yes or no) Comments: s; ,(note condition of pump chamber, condition of pumps and appurtenances, etc.) N r (revised 8/15/95) L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C... , SYSTEM INFORMATION (continued) Property Address: 1 Oct Owner: � - -.. ._. pate of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain:,,,. Type: leaching pits, number: _ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS.. (locate on site plan) P Number and configuration: I Depth-top of liquid to inlet.invert: ` Depth of solids layer: Depth of scum layer: —_ Dimensions of cesspool:..-.. .. Materials of construction: -" Indication of groundN%ate:. inflow (cesspool must be pumped as part of inspection) - Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on 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.) B (re,Yised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,Oct (,u16 r � ,rY c.� --wzle Owner: Date of Inspeclio SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' c� a R PC E D'Bcx U - all g o'>come-C +o ►�- �- as DEPTH TO GROUNDWATER Depth.to groundwater: JD feet r method of determination or approximation: —Z�t' ��O�L,`z<�c� ca— 'f i!1-bum U..S C�S I��r (revised 6/15/95) 9