HomeMy WebLinkAbout0033 BEACH PLUM HILL ROAD - Health 33 Beach Plum .Hill Road
ivfarstons Mills
A-007-005-005
r
` Commonwealth of Massachusetts
W Title 5 Officiai Inspection For
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ssments
`M 33 Beach Plum Road-s sterrft 2 of 2
Property Address
Herbert Pheene
Owner Owner's Name i
information is r.
required for every Marstons Mills MA 02648 12/12/2013
page. City/Town State Zip Code Date of Inspection
Y
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, 4
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
key the return Name of Inspector
Y ;
rab Company Name '
P.O. Box 49
Company Address ,
Osterville ;I MA 02655
City/Town State
508-862-9400 ' State Zip Code
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 tale, 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
yNeeds er valuation by the Local Approving Authority
12/12/13
e ector 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 god 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 describesscIcopnditions 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.
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i
Commonwealth of Massachusetts
W Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;u 33 Beach Plum Road -system 2.of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills I MA
page. City/Town 02648 12/12/2013
State Zip Code Date of Inspection
B. Certification (cont.) 1
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any info.Fination which indicates that any of the failure criteria described
in 310 CMR 15.303 or in. 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
I,
❑ 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.
II. h
Check the box for"yes", "nql'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):
it
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of Massachusetts
• Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 33 Beach Plum Road -system 2 of 2
Property Address
Herbert Pheene i
Owner information is Owner's Name
required for every Marstons Mills MA 02648 page. City/Town State 12/12/2013
Zip Code Date of Inspection
B. Certification (cont.)
/alarms not operational. System will pass with Board of Health approval if
El Pump Chamber pumps
Pumps/alarms are repaired.
B) System Conditionally,Passes (cont.):
i
❑ 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):
li
❑ broken pipe(s)'a rereplaced ❑
I; Y El El ND(Explain below):
El obstruction is removed ❑ Y ❑ N
.. C ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
b
❑ The system required pumping more than 4 times a year due to broken or obstructed The
system will pass inspection if(with approval of the Board of Health): pipe(s).
❑ broken pipe(s)are replaced ❑ Y ❑ N
. Ii, ❑ ND (Explain below):
ij: 9..
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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C) Further Evaluation is Required by the Board of Health:
F.
ElConditions 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
is
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
• Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
i
°M 33 Beach Plum Road -s stem'2'lof.2
Property Address
Herbert Pheene
Owner information is Owner's-Name o
required for every Marstons Mills MA 02648
page. City/Town 12/12/2013
State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail uniJess the Board of Health (and Public Water Supplier, if a determines that the sy4tem 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 flank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determ,ine'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: IR
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
j ,
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogge8 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 de'pth in cesspool is less than 6" below invert or available volume is less
than Y;day flow
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
k '
I'
Commonwealth of Massachusetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Beach Plum Road -system 2"of 2
Property Address
Herbert Pheeney '
Owner Owner's Name
information is
required for every Marstons Mills MA 02648
page. City/Town State 12/12/2013
B. Certification (cont.) Zip Code Date of Inspection
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.
❑ ® An ort.ion of a cesspool or privy is within a Zone 1 of a public well.
Y p,.
El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El Any potion 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 s'stem is a cesspool serving a facility with a design flow of 2000gpd-
10,00apd.
❑ ® The s�stem 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 ito'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
i. .
❑ ❑ 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"t�any question in Section E the system is considered a significant threat,
or answered "yes" in Sectim,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 3;10CMR 15.304. The system owner should contact the appropriate
regional office of the De partrrtent.
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
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Commonwealth of Massachusetts
Title 5 Offi i `c�q:l Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Beach Plum Road -system 2,of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills I' MA 02648
page. City/Town 12/12/2013
State Zip Code Date of Inspection
C. Checklist Y
a
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ PumpAg information was provided by the owner,'occupant, or Board of Health
❑ ® Were arty of the system components pumped out in the previous two weeks?
® ❑ Has thosystem received normal flows in the previous two week period?
❑ ® Have IaFge 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?
® El 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:
® ❑ Existinginformation. 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)]
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D. System Information
Residential Flow Conditions:
, a
Number of bedrooms (design):: 4+ Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
N;
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°. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
1
Commonwealth of Massachusetts
Title 5 Officil Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assseessments
I,
`M 33 Beach Plum Road -s stem 2 of 2
Property Address
Herbert Pheene
Owner Owner's Name r
information is
required for every Marstons Mills MA 02648
page. Cityrrown 12/12/2013
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
information in this report.) I' ❑ Yes Z No
Laundry system inspected?',
❑ Yes ® No
Seasonal use? Pa
I�
' ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: �9 currently
Date
Commercial/Industrial FloW Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/pe(sons/sq.ft., etc.):
Grease trap present? El Yes ❑ No
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged,to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
t:
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i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Ins ection Form
Subsurface Sewage Dispos I System F -Not for Voluntary Assessments
33 Beach Plum Road-system 2.of 2
Property Address
Herbert Pheene I'
Owner Owner's Name
information is
required for every Marstons Mills 0 MA 02648 12/12/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
I! Date
Other(describe below):
is
General Information
II i
Pumping Records:
Source of information: unavailable
Was system pumped as part.of the inspection? ® Yes ❑ No
If yes, volume pumped: d I 1500
gallons
How was quantity pumped determined?
Reason for pumping: maintenance
Type of System:
® Septic tank; distribution box, soil absorption system
I' i
❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
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a
I
Commonwealth of Massachusetts
W Title 5 Official` Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary y Assessments
;M ,•` 33 Beach Plum Road-s sterrr 2 of 2
Property Address
Herbert Pheeney
Owner Owner's Name
information is
required for every Marstons Mills is MA 02648
page. City/Town 12/12/2013
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
installed - unknown date
i
Were sewage odors detected when arriving at the site?
❑ Yes ® No
Building Sewer(locate on�site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ® 40 PVC
❑ other(explain):
Distance from private water,supply well or suction line:
t' feet
Comments (on condition of,joints, venting, evidence of leakage, etc.):
ii
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Septic Tank(locate on site�pla'n):
Depth below grade: 18"
feet
Material of construction:
® concrete ❑ m(etal ❑fiberglass ❑ polyethylene
❑ other(explain)
ti..
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500galsgals.
Sludge depth: 2"
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
_ _ Title 5 Official' '
Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 33 Beach Plum Road-system' 2 of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills Y MA 02648 12/12/2013
page. Cityrrown
State Zip Code Date of Inspection
D. System Informatiot (cont.)
Septic Tank(cont.)
kl
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Distance from top of sludge to bottom of outlet tee or baffle 15
Scum thickness 4"
Distance from top of scum 'to'top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 12kk
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
There were no signs of leal8age. Recommenend pumping every 2 years The cover was 3" below
c
ti
Grease Trap(locate on site:.pl$n):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ me al`. ❑fiberglass ❑ polyethylene
El other(explain):
N/a
Dimensions: r
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
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Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 10 of 17
tl
• Commonwealth of Massachusetts
v Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form Not for VoluntaryAssessments sessments
`M 33 Beach Plum Road -system 2 of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. Cityrrown
State Zip Code Date of Inspection
D. System Informati n (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to ou6et invert, evidence of leakage, etc.):
ti
Tight or Holding Tank(tankMust be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal., ❑fiberglass
t; 9 ❑ polyethylene ❑ other(explain):
N/a
a,
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: w ❑ Yes ❑ No
it
Alarm level: — Alarm in working order: ❑ Yes ❑ No
q
,
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
q
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Beach Plum Road-system:2 of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648
page. City/Town 12/12/2013
D. System Information (cont.)
State Zip Code Date of Inspection
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 normal. !'
1
1
.Pump Chamber(locate on site plan):
i
Pumps in working order: ❑ Yes ❑ No*
�.
Alarms in working order: !:
❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/a
a ,
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* 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):
i
If SAS not located, explain why:
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i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
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1
Commonwealth of Massachusetts
• Title 5 Official
_ cial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
k
`M 33 Beach Plum Road -system,2 of 2
Property Address
Owner
Herbert Pheene
information is Owner's Name
required for every Marstons Mills MA 02648
page. City/Town 12/12/2013
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pith number: 1 -6'x6' 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.):
The pit had 6"of water on the.bottom.There was no signs of failure The cover was 15" below.
9`
6;
is
Cesspools (cesspool must be.pumped as part of inspection) (locate on site plan):
t
Number and configuration N/a
Depth—top of liquid to inlet invert
, e
Depth of solids layer
Depth of scum layer
Dimensions of cesspool f
r.
Materials of construction
ai
Indication of groundwater inflow ❑ Yes ❑ No
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Mastachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal Pystem Form -Not for Voluntary Assessments
, 33 Beach Plum Road -s stem 2.of 2
Property Address
Herbert Pheene
Owner Owners Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. City/Town p
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.):
f;
Privy(locate on site plan):
Materials of construction: e
Dimensions
z
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a '
FF
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
d
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposi'l System Form -Not for Voluntary Assessments
33 Beach Plum Road-s stern' .of 2
Property Address i
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648
page. Cltyfrown State 12/12/2013
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
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Mor.
A (3
► 5") *3
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Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
f
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
��a •`'�' 33 Beach Plum Road -s stern'2 of 2
Property Address
Herbert Pheene )
Owner Owners Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. City[Town
State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope I
® Surface water
❑ Check cellar
i
❑ Shallow wells
Estimated depth to high ground water: - 24'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from System design plans on record
If checked, date.pf design plan reviewed:
r i Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Using topo and"water contours maps
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
r
You must describe how you established the high ground water elevation:
see above +;
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li 5
e
Before filing this Inspectio r n Report, please see Report Completeness Checklist on next page.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
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• r Commonwealth of Massachusetts
Title 5 Officia1l Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`M 33 Beach Plum Road -System 2,of 2
Property Address
Herbert Pheene
Owner information is Owner's Name t.
required for every Marstons Mills MA 02648
page. City/Town 12/12/2013
?. State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A„B, C, D, or E checked
® Inspection Summary D;(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins-3/13 '
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form,
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
33 Beach Plum Road -s stem 1 of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills ' y MA 02648 12/12/2013
page. City/Town
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your I /}
cursor-do not James Ford LJ
use the return Inspector
Name of Ins
key. P
rab Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town Zip Code
State
508-862-9400 r S ate
Telephone Number 12482
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 DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Furth r valuation by the Local Approving Authority
12/12/13
Inspe is Signature
Date
The tern inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13
Title 5 Official Inspection eubsu,.ce Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
v Title 5 Offici l Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntarym
Assessments
33 Beach Plum Road-system' 1 of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648
page. City/Town State Zi Code 12/12/2013
P Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
k:
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 explaint
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 E ND (Explain below):
ii .
8
I
f
r;
t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
4'
Commonwealth of Massachusetts
. Title 5 Officia`I Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments q y
� 33 Beach Plum Road -s stem' 1-of 2
Property Address
Herbert Pheene E,
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. City/Town 9' Zi Code Date of Inspection
P
B. Certification (cont.) State
❑ 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
I
pass inspection if(withapproval of Board of Health):
❑ broken pipe(s).'are replaced ElY ElN ElND (Explain below):
i
Elobstruction is removed ❑ 'Y ❑ N ❑ ND (Explain below):
❑ distribution boz-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):
El broken pipe(s)eye replaced ❑ Y ❑ N ❑ ND (Explain below):
•i
❑ 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.
Y
I. System will pass un'le'ss 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
l
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I• ;
Commonwealth of Massachusetts
als Inspection For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments'
Title 5 Offici
i
33 Beach Plum Road -s stem 1;of 2
Property Address
Herbert Pheene
Owner information is Owner's Name
required for every Marstons Mills I MA 02648
page. City/Town 12/12/2013
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:
i
❑ 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. ;;r
❑ The system has aseptic.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 determ�',ine 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:
i`
1'
D) System Failure Criteria Applicable to All Systems:
I
You must indicate"Yes" or,"No"to each of the following for all inspections:
I
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 Y2 day flow
15ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
1
�i
Commonwealth of Mas'AAthusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Beach Plum Road -s stem 1 of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12/12/2013
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�ortion 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
systeri pwner 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 id.15,000 gpd.
t
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 syte.m is within 200 feet of a tributary to a surface drinking water supply
El ❑ 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 and CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
`, a
ii
Commonwealth of Massachusetts
Title 5 Officia Inspection Form
Subsurface Sewage Disposal 1,yytem Form - Not for Voluntary Assessments
;M 33 Beach Plum Road -system 1'.aof 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills page. City/Town ; MA 02648 12/12/2013
C. Checklist State Zip Code Date of Inspection
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
r ,
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has thit?,Sy stem 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?
® El Was thp:site inspected for signs of break out?
r: ,;'
® El 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,
dimension's, 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 d ermined based on:
ii: , .
® ❑ 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 1n 4+
desi 4
( 9, ) Number of bedrooms (actual):
DESIGN flow based on 310;CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 "
i '. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
L '
Commonwealth of Massachusetts
Title 5 Official' Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Beach Plum Road -s stem;i 1 Hof 2
Property Address i
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648
page. Cityrrown 12/12/2013
State Zip Code Date of Inspection
D. System Information
Description:
F'
1 ;q
B�
ti y
i
Number of current residents:: : 2
Does residence have a garopi�e grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? i [I Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
unavailable "
y.
i
Sump pump? ii
❑ Yes ® No
Last date of occupancy: currently
t
Date
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 ElNo
Water meter readings, if available:
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
�' 1
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Beach Plum Road -system 1 of 2
Property Address
Herbert Pheene
Owner 9
information is Owner's Name ,
required for every Marstons Mills MA 02648 12/12/2013
page. City/Town State -ZIPCode
Date of Inspection
D. System Information (cont.)
Last date of occupancy/use
Date
Other(describe below):
General Information
Pumping Records:
I j
Source of information: unavailable
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined?
Reason for pumping: maintenance
Type of System: I
® Septic tank,,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy t' '
❑ 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):
l5ins-3f13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
t
,
Commonwealth of Massachusetts
• Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
33 Beach Plum Road -s ste 11:1 of 2
Property Address
Herbert Pheene
Owner information is Owner's Name `•
required for every Marstons Mills page. Ci MA 02648 12/12/2013
ty/Town State Zi i P Code Date of Inspection
D. System Information (conQ
Approximate age of all components, date installed (if known)and source of information:
installed - unknown date 5
Were sewage odors detected when arriving at the site?
❑ Yes ® No
i
Building Sewer(locate onsitq plan):
i
Depth below grade: ? ,
feet
Material of construction:
❑ cast iron ®40 4PVC
❑ other(explain):
Distance from private water'supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
l+ 1
Septic Tank(locate on site;plain):
Depth below grade: 15"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene
y thylene ❑ other(explain)
5
i �
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gals.
Sludge depth: 2"
t5ins•3/13 '
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
7 '
I
r ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Beach Plum Road-system; 1'of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. City/Town
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 15"
Scum thickness " ' 2"
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? measured
Comments (on pumping re gmmendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
There were no signs of leakage. Recommenend pumping every 2 years
i.
Grease Trap(locate on site,plan):
Depth below grade:
feet
Material of construction:
1
❑ concrete ❑ metal ❑fiberglass polyethylene
,. ❑ other(explain):
N/a
Dimensions: ;
lG ,
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
M
Commonwealth of Massachusetts
W Title 5 Official' Inspection Form
aS Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 33 Beach Plum Road-system 1°of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is `
required for every Marstons Mills MA 02648 12/12/2013
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.):
r� g
I
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction: I
❑ concrete ❑ metal El fiberglass ❑ polyethylene
+.. s fib ❑ other(explain):
N/a r,
I,
Dimensions:
Capacity:
gallons
Design Flow: ,
U gallons per day
Alarm present: i
❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes El No
i
Date of last pumping:
Date
Comments (condition of alal:m and float switches, etc.):
rh
' 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
a
• Commonwealth of Massachusetts
Title 5 Official Ins Inspection Form_ o p rm
Subsurface Sewage Disposal $yytem Form -Not for Voluntary Assessments
33 Beach Plum Road-system' 1!of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. Cityrrown
State Zip Code Date of Inspection
D. System Informati�n (cont.)
Distribution Box(if present must be opened)(locate on site plan):
1 .I
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''dut of box, etc.):
The D-box was normal.
i
Pump Chamber(locate on�site plan):
Pumps in working order: t ❑ Yes
❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/a
i
* If pumps or alarms are not,in working order, system is a conditional pass.
Soil Absorption System ( ^AS) (locate on site plan, excavation not required):
If SAS not located, explain why:
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
t
Commonwealth of Massachusetts
W Title 5 Official) Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M ,•• 33 Beach Plum Road -system:1 of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 -6'x6' 1000
l 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.):
The pit had 6"of water on the'bottom.There was no signs of failure.The cover was 6" below.Note:
recommend removing bush`that is growing right next to the cover. It will impede access to the pit in
the future.
i
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/a
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer q .
l
Dimensions of cesspool is
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
1
< Commonwealth of Massachusetts
H Title 5 Official Inspection Form
orm
Subsurface Sewage Disposal System
p , y em Form Not for Voluntary Assessments
33 Beach Plum Road -system, of.2
Property Address
Herbert Pheene
Owner Owner's Name 4
information is
required for every Marstons Mills page. Cit yfrown MA 02648 12/12/2013
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.):
t
i;
Privy(locate on site plan): i
Materials of construction:
Dimensions a
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
i
r
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
n'
Commonwealth of Massachusetts
_ 4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 33 Beach Plum Road-system 1:of 2
Property Address
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12/12/2013
page. Cityfrown
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
E:
6
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Ful
Q
I!
Q O
i0% r
a a0l ao
3 ys 3G
y sg ys
t5ins•3113 ,
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
}
I
Commonwealth of Massachusetts
. Y
Title 5 Official Inspection Form
Subsurface Sewage Disposil System Form -Not for Voluntary Assessments
M 33 Beach Plum Road-system 1.of 2
Property Address +
Herbert Pheene
Owner Owner's Name
information is
required for every Marstons Mills " :i MA 02648 12/12/2013
page. City/Town State Zi Code
P Date of Inspection
D. System Information' (cont.)
Site Exam:
❑ Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 24'
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:
1; ' , Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Using topo and water contours maps
a
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
y
You must describe how you�established the high ground water elevation:
see above
t. .
i
Y �
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
4"
1 .i
Commonwealth of Massachusetts
T W Title 5 Official Inspection For
m
rm
Subsurface Sewage Dis
posal sposal System Form Not for Voluntary Assessments
;M 33 Beach Plum Road-s ste 1.1',of 2
Property Address
Herbert Pheene
Owner Owner's Name +
information is I,
required for every Marstons Mills page. City/Town MA 02648 12/12/2013
State Zip Code Date of Inspection
E. Report Completer `ss Checklist
® Inspection Summary:A,IB, C, D, or E checked
® Inspection Summary Dl(�ystem Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l;
Jr
Ci p
a
t`
s
F
h. •
is
{� 1
a
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
"- �OV/16/2006/THU 13;01 I ppIME Tp AI' Parker P. 002
Hazardous Materials Specialist
FORM F.P. 292 I 9 MA-M � Town of Barnstable
(rev. 9/90) i $"TFu Ma+ Department of Regulatory Services
Office Hours: PUBLIC HEALTH DIVISION
8:30a -9:30a 200 Main Street, Hyannis, MA 02601
( ) Tel: (508) 862-4644
f,? Fax: (508) 790-6304 .
http://www.town.barnstable.ma.us/Health/HelpfulLinks.asp 3'ie Safety
l� ,
Email: alisha.parker@town.barnstable.ma.us ' and Regulation
ulq
n
APPUCATION Fo h per, AND PERNT, FOR REMOVAL AND TRANSPORTATION. TO APPROVED TANK YARD !1 �G
01920 Date July 26• 1 . 91
FDID# Permit _-- -
Osterville ��JG�/1'►�/,
city.V"n or District c . 82 S . 4 0 14 . G . L .
• ���'_vim( '% �i
Cy � DIG SAFE p3UMRFl2
Fee Paid:S 10.00 91294486
start date July 26, 199 !i
i~'... 9c� 0�
In accordance with the provisions of Chapter '1�I8., Sec. 3 M.
527 CMR 9.00 application is hereby made by.
Atlantic Tank
P.O. Bog 94, S. Dennis, MA
Street Address & City or Town:
Signature of applicant:
Applicants name printed,
For permission to remove and transport one undergroun storage tank from.
Staniar Residence 3 ecb. 1um Hall Road, Ost -
Owner: Street Address:
Firm transporting waste: State Lic.#
Hazardous waste manifest # B.P,A•#---�-- --
Approved tank yards Abandandment 'NSA _
Tank yard Addresss N/A
Type of inert gash NSA _ UL tank #:
Tank capacity: i ,nnn Substance last stored: #2 Fuel Oil
Date of issue:_July 26, 12 91 Date of expiration: August 9, 1,991�
Si nature Title of Officer granting permit:•
9 / - f
(KEEP ORIGINAL AS APPLICATION AND ISSUE DUPLICATE AS PERMIT
Fmd Map/Parcel 4 090005005 I F � T,own of Barnstable
Health Department Health system �
a h
�rym
Map/Parcel; 090055005 � �
Tank Nbr 1 ;' TagNbr InstalledLocation �B
x
Test Notification Date £f� / tatus ®ate v
ON
Removal No ifidghu' nn Date
Test RA
yAbandon
08/09/1991
Removals `
y�/� / Variance P �
F u e I S',:' IFO MgqTFu1,P,ROM vWell
R ason
s; Cap city Construction Leak Detection Cathodic Detection
�Atna abandoed in place
/ .
Change Prdl ,�,�
.F
�22 2 TOWN OF BA1.R1 INSTABLE Sysr" � Z
LOCATION 33 QCAf� 1'"IUVV� 14 1 I Rc-j SEWAGE #
VILLAGEdA40AT MiIIS ZSepyi+ ASSESSOR'S MAP & LOT O "1 00S
INSTALLER'S NAME&PHONE NO. hQT
SEPTIC TANK CAPACITYD
LEACHING FACILITY: (type) 1OXto 1/000 64 (size) � � Sro^t-
NO. OF BEDROOMS a JJ
'BUILDER OR OWNER tAIA [X. S7-4,1; l r
PERMITDATE: COMPLIANCE DATE:
t
`Separation Distance Between the:
Maximum Adjusted Groundwater Table
� b e to the Bottom of Leaching FacilityFeet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by 137 Fol�
a0or AM
q� y
t
3
1 aY /s fi
a aq ao
3 y S 3lv � Y
;..y 152f ys'
TOWN OF BARNSTABLE
LOCATION � 6"U( I- r O lu, 14.11 SEWAGE #
VILLAGEMAr3n,i /Vl► 1 / .Stpv►t ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (,,X6.' /M ! Al- (size)
NO. OF BEDROOMS C
BUILDER OR OWNER WA Cre, VAll/*,4
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility). Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leacng facility) Feet
Furnished by TA5,Mc. ro.� 77Ir//'�ord
FrO�T
'Door 84*1
Gnn2ow
I
I
4 a
1l/ S7 35'6
a So 3
3 o y
3 37 3l0
it
y yo, b ply
L 0 C A,T ION r/,/ SEWAGE PERMIT NO.
dee-e-13
V I L.L A G E Vo,., 9 A �6��j �o a�? -711
INSTA LL R'S, NME i ADDRESS
OR OWNER
J
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ���� � �
V7
J�
L0CA,TIQN f-/r// SEWAGE PERMIT NO.
VILLAGE
INSTZALY'S� NAME i ADDRESS u =
*6+fff R OR `O W NNwE�Ry
DATE PERMIT ISSUED _/�� -- 1
DATE COMPLIANCE ISSUED � �, _ �
r
r--
f
•1
3 �
No.. l ......_.. Fxls..............................
THE Ct �MMOWWEALTH OF MASSACHUSETTS
: O
BOARD OF HEALTH MAP
PARCEL
Appliration. for Disposal Works Tomitr n rr ` - �� 2 4
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: `
!"'9uW-ft.....A --a OL............................. --•-•------..........-----......--....----------
or
canon-Address •-------•................................... Lot No.
Owner Ildd,er.
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---x:;L...................................Expansion Attic ( ) Garbage Grinders)
Other—T n
a ype of Building -_.Re,T_______________ No. of persons------ Showers Cafeteria ( )
d Other fixtures ------------------------------------------------------
----------------------------------------------------------------------------------------------
W Design Flow.__.13Z............................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity j&---_gallons Length................ Width---------------- Diameter---------------- Depth----___.-_-_-__.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_-__-___-___-___--sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY------- ----••----------------•-----------•----•-----..._---••------------ Date----------- ----------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----_-__________._--.-_.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---___-______________-_.
a ------------•-----•-------------- --------•................................................................................................................
0 Description of Soil-----0-!- ---- ? ....i _.. -----------------------------------------------
x
x ............� -�---------NY C -�.....-----...5'—------_--���_.�J------------------------------------------------------------
V Nature 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 Article 1I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...: == "i/ -------------- --------------------------------
Date
Application Approved B �. i.....
PP PP Y = ------------------------- ------ -----------
Date
Application Disapproved for the following reasons----------------------------------------------•-----------------------------------------------------------.
---------------------------------------------------------------------•-------•--••-•------------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
IVo. .9 SSe.. _ Fm&3.4. �..---.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
. . ...... ....... ......... .....OF.........................................................................................
1
Appliration for Disposal Works Tonotrnrtion rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•---------------------------'-----...-------•----------------------......_...•--......'--'•.._..._ ._.....------••-•--------..........---._..._..........•'--•-----------------•-•---•--••--••-•---.
Location-Address or Lot No.
•----'--------------------------------------•--....---......................._..........._........ ........•.............•-•-----•-------•---------------•-••------•-------------•---•......-•-•-----
Owner Address
W
Installer Address
d Type of Building Size Lot------------------_---------Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder if)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
A4 Other fixtures -------------------------------
W Design. Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic.Tank—Liquid capacity-------------gallons Length---------------- Width----------...... Diameter---------------- Depth__---__--__.._-.
x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq, ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..__........
O Description of Soil ----------------------- : ------------
V ---------------------------------------------------------------------------------------------------------------------------------------------------'------------..
iJ_a......... .S1 " ..r. r4p ..---------,00.<A-,rt -------------------------------------------I
Nature 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the bo rd of health.
Signed J ^-t • = ----------- --------------------------------
i --y L�tr Date
Application Approved By-•-••-....._--- L -- /V..•- -A -- ---------•--•------•-------• `
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------•--------------......------------.......-----------------------------------------------------------------------------------------------
Date
PermitNo........................................................ Issued........................................................ i
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF............... ...
(9rdif irafr of Tomptittnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System cpnstructed ( or:, Repaired ( )
by--------------- /'c�: . ... --
/'�� Instal �,/
has been installed in accordance with the provisions of Arti I of The State Sanitary Code as described`in the
application for Disposal Works Construction Permit No... e�.. S;SB............... dated..............._.................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................... 2"` ............... Ins ector.-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:.............OF......yam
N ��................. FEE.' -e.............
Ubpooal ork Con $rnr ion prutii
Permission is h eby granted_________ ._, ...... . -_ •�.-___________________F_
G�-�- ,=
to Construct ( Repair ( ) Individual Sewage Disposal System
atNo. r -lr, s -------------------- ---------------------------------------------------------•----
Street
as shown on the application for Disposal Works Construction Permit N,00..................... Dated------------------------------------------
.......................................
L
DATE.................. , 1 ...................................... B of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
APPLICATION FOR PERCOLATION TEST ATD OBSERVATION PITS
LOCATION ` I.rC, CI{ PVl. V" (�-.Q- 1 �r ��-•, c3f4 SWwr-s V4uZYNO. -�8�
+!% ?
VILLAGE <fe5T t-p-V L DATE-7 �l
;APPLICANT G �&Jk, S%f6L Ara o,
FE i
'ADDRESS (Non'-refundable
TELEPHONE NO.
}ENGINEER 4 IJqp •r �,/' / 5 TELEPHONE-NO.
,DATE SCHEDULED ---
<+ � �9u G- y /fr�l
; j ;
(Applicant's signature
• • O • • • • • • • • • •O • . .. .
C i SOIL LOG
SUB-DIVISION NAMES �`r1 DATE ry g TIAIEP 3�
W
d j EXPANS ION'AREA: YES 'ENO ENGINEER
:TOWN WATER _liPrRIVATE WELL {-5 BOARD OF HEALTH
4
EXCAVATOR
't 'SKETCH: (Street name,etc. ,dimgnsions of lot, exact location*' of test holes and
percolation tests, locate wetlands in pr" x ' ty to test holes)
NO
44
p.
t! P J
PERCOLATION RATE:
a ::
.TEST HOLE NO: EL NATION: TEST HOLE NO: ELEVATION:
.3 1 1 ;
3 3 !
4 4 _ M i
a 5 5
; .
' 6 J 6
i 7 7
8 i. . 8
• .ya i 10 1O
x
12 12
13 o wQ 13
14 14
1,5 15 11
16
16
j SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIEL ING PITS C--'
ij LEACHING T ENCHES
'UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: (i
i )NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED. ON PERC TEST APPLICATION
a '
rUIORIGINAL: ?COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
.. COPY: iRETAINED BY APPLICANT
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