HomeMy WebLinkAbout0085 BLACK OAK ROAD - Health 85 Black Oakt Road
Marstons Mills
A= 101-068 �`
r •
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown 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 filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key �sq
to move your MARK L WHITE
cursor-do not Name of Inspector
use the return
key. NEIGHBORHOOD WASTE WATER
Company Name
350 RT 28
Company Address
WEST YARMOUTH MA 02673
' Cityrrown State
Zip Code
508-775-2820 S113381
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 arr a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑X ❑ El � (N Ot'ti7q �iii
Passes Conditionally Passes ..Ssy%,�
s o
Needs Further Evaluation by the Local Approving Authority _ MARK ym
_ WHITE
o
=L'- No.S13381 cn
yr' : yr
nDECEMBER 12, 2012 ''4��F ... ..\
Insp ctor's Signature Date '
The system " submit a copy of this inspection report to the Approving Authority (Board
of'Mal'th or DERrvvithrin-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
nd copies s nt tote ,uyer, if applicable, and the approving authority.
****This report only describes conditions at.the time of inspection and under the conditions of use
a thljglis�i�"�;gection does not address how the system will perform in the future under
the same or different conditions of use. I� 0
t5ins•11/10 Title 5 Official Insp ion rm.Subsurface Sewage Disposal System•Page 1 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for MARSTON MILLS
every page. MA 02648 DECEMBER 12,2012
Cityfrown 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:
❑x I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved
by the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
❑ 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):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
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
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. I
❑ 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.
ti
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 20
E Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for
every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
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
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ z Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool
❑ ❑x Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last year NOT due to clogged or
El FX obstructed pipe(s). Number of times pumped:
❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ C Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ C 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
El C' well.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Citylrown State Zip Code Date of Inspection
❑ ❑x 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.]
❑ ❑x The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ FX1 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.
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
❑ N Has the system received normal flows in the previous two week period?
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
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)N/A
❑x ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑x ❑ Was the site inspected for signs of break out?
❑x ❑ Were all system components, excluding the SAS, located on site?
❑x ❑ 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?
❑x ❑ 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:
❑x ❑ Existing information. For example, a plan at the Board of Health.
❑x ❑ 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): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
D. System Information
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
Description:
Number of current residents: 1
Does residence have a garbage grinder?
z Yes ❑
No
Is laundry on a separate sewage system? Cif yes separate inspection required] Yes ❑
No
Laundry system inspected?
❑ Yes ❑
No
Seasonal use? ❑x Yes ❑
No
Water meter readings, if available (last 2 years usage (gpd)):
2010-20,000 GALLONS 2011-17,000 GALLONS
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 20
y Commonwealth of Massachusetts
v: Title 5 Official Inspection Form
�e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
x
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
Sump pump? z Yes ❑
No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 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? El Yes El
No
Water meter readings, if available:
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: B.O.H.
Was system pumped as part of the inspection? ❑x Yes ❑ No
If yes, volume pumped: 1000 GALLONS
gallons
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
x
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
How was quantity pumped determined? TANK MEASUREMENT AND TRUCK GAUGE
Reason for pumping: MAINTENANCE
Type of System:
❑x 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):
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
5/25/84 PERMIT ON FILE AT B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ❑x No
Building Sewer(locate on site plan):
Depth below grade: 30 INCHES
feet
Material of construction:
❑ cast iron ❑O 40 PVC ❑ other(explain):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Dorm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
CitylTown State Zip Code Date of Inspection
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.): INSPECTED MAIN LINE WITH
SEWER CAMERA, LINE IS CLEAR
Septic Tank(locate on site plan):
Depth below grade 18 INCHESfeet
Material of construction:
❑x 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:
Sludge depth: 3
D. System Information (cont.)
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 20
Commonwealth of Massachusetts
Q Title 5 Official Inspection Form
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 4
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.)
INLET AND OUTLET CEMENT BAFFLES IN PLACE, NO SIGNS OF LEAKAGE
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
City/Town State Zip Code Date of Inspection
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
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.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 20
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityrrown State Zip Code Date of Inspection
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert AT INVERT
I
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.):
DISTRIBUTION BOX IS IN GOOD SHAPE
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.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 20
Commonwealth of Massachusetts
Title 5 Official Inspection Dorm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for
every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
City/Town State Zip Code Date of Inspection
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
D. System Information (cont.)
Type:
❑x leaching pits number: 6X6
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 20
Commonwealth of Massachusetts
VA Q Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�e
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Citylrown State Zip Code Date of Inspection
❑ 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.) SOIL IS DRY, NO SIGNS OF HYDRAULIC FAILURE, THERE IS 40" FROM INLET
TO LEACH PIT TO LIQUID LEVEL
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
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 20
Commonwealth of Massachusetts
iv,r
Title 5 Official Inspection Form
x
e
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Cityfrown State Zip Code Date of Inspection
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 20
Commonwealth of Massachusetts
r, Title 5 Official Inspection Form
�e
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for
every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Citylrown 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
❑x drawing attached separately
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 20
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑x Check Slope
❑x Surface water
(] Check cellar
❑x Shallow wells
Estimated depth to high ground water: 14 FEET
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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 20
Commonwealth of Massachusetts
ON V, Q Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ 85 BLACK OAK RD
Property Address
Owner JOSEPHINE WALKER
information is Owner's Name
required for every page. MARSTON MILLS MA 02648 DECEMBER 12,2012
Citylrown State Zip Code Date of Inspection
You must describe how you established the high ground water elevation:
PERFORMED AN AUGER HOLE DOWN TO 14 FEET WITH NO GROUNDWATER ENCOUNTERED.
BOTTOM OF LEACHING IS AT 9 FEET.
Before filing this Inspection Report, please see Report Completeness Checklist on next
page.
E. Report Completeness Checklist
❑X Inspection Summary: A, B, C, D, or E checked
❑X Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑X System Information—Estimated depth to high groundwater
❑X Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 20 of 20
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Application is hereby made for a Permit to Construct.4 ) or Repair ( ) an Individual Sewage Disposal
System at:
T of # 6 - Black Oak Rd. e.. Yiarstons Mills ;, I'fiA
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dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedreoms ...........................................Expansion Attic ( ) Garbage Grinder
Other—Type of Buildin ranch .... No. of ersons............................ Showers ( )
g P ) — Cafetep
d Other fixtures .................................................... -----------------------------
--------------------------............
•-•----.---.--
W Design Flow......hh...:............................gallons per person per day. To al daily flow.._....a39..._.......................�gallons.
WSeptic Tank—Liquid capacit�•.000...gallons LengA ............. Wil..l�._..... Diameter................ Depth..-._-_•.......
x Disposal Trench—No. .................... Wid h................... Total Length....b i-------- Total leaching area ........sq. ft.
Seepage Pit N�..:.................. Diameter._........._.__..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosm ,t nk )�� re e Engineering 11-25-81
'~ Percolation Test Results Performed by.r:l g ..... ....................................... Date.............._.__..._..................
2.0 p P 12 Depth g one encounter
Test Pit No.,,�,1.`. .............minutes per inch Depth of Test Pit... ....__....._.__. D th to round wat --_-/l.___--_.--•----__. —
f 1PL.A..._..._._nunutes per inch Depth of Test PWIA.............. Depth to ground water!.!l_ti..........._... e
Gz., Test Pit No.
G4 ....•-•.•••--•--•-----------••.......-•----••••...................•••-•.._....................-•-•--..........................................................
0 Description of Soil........Q'_.__-.-_2.'.__......loam & topsoil
�4 2' _ - 10' Tviedium---�rellow sand•-------------------••-•--------.....--- ----------........_..-----------•
W 10.............
- i2 med. white sand/traces_.of__graveTfrio_::inia:E a�:::12
VNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
-- ��-� rr�l a Gectificate of Compliancy.has - n i!;sued by the board_gM- ealth.
.-..y L._ t -�:.-� �'',,yy -Iv OJ i7 e✓..-.�1_'.G\„r--,�_F�✓/ (/-/ „v.
v'V v
i
No.,)...`. ..... Fmc.:�..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
..... .........................OF........................................----.._...._..--------...._...-- ...........
Appliration for Di,4poiittl Vork.o Tontrnrtiton amit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot # 6 - Black Oak. Rd.__, __Yia�rstons Mills ;, MIA
--.....-•---------•. •--- --- ...................................•-....---•-.._.........----•-------•..........•--....._........
Capricorn Rebtfft r ilbst 765 Falmouth Roqd&;NHyannis
W Steve Lebel owner Address
a ............................................... - -._.............
� Installer Address
d Type of Building Size Lot............................Sq. If
Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder
Other—Type of BuildingranCh............... No. of persons............................ Showers ) — Cafete •a ( )
Q' Other fixtures ----------------------------------•-••• . •.
W Design Flow......0...............................gallons per person ppr day. To l� ilx�flow.._....33......._...._.._............ t Ions.
WSeptic Tank—Liquid capacity 000 gallons Lengt§___b_......... Widt................. Diameter................ Deptl�...`.I......
xDisposal Trenc�—No. .................... Wid j...._._.._.._._._.:Total Length ........... Total leaching area---- _ . -. sq. ft.
Seepage Pit N ... Diameter.................... Depth below inlet................ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosin�lt�rlk (,
.. re gee Engineering 11-25-81
Percolation Test Results Performed by.........�;------ .:--,-.........-. V-------------------------- Date..............._........................
0 -~ -- �2 one encounte -
,� Test Pit No. 12................minutes per inch , Depth of-Test Pit..........__._.._.. Depth to ground wat ,_.. _......._.
r
f= Test Pit No. A......._._minutes per inch . Depth of Test Pi��..A............. Depth to ground water........................
e
O 0 ' - 2' loam & to soil - '
Description of Soil. - - - ..
,..
x 1.0-,-------hediizm ye ,--....................---: - -
w -------------------------------------1.0-r-------1�-'.......fried...white -sanditraces _6*T-�rav&1' HU.water at 12
U 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 TITLE 5 of _he 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.---------••---...--•-•----------------------•------..........-•--•------PY'2S.
Date
ApplicationApproved By.................................................................................................. .......................................
Date
Application Disapproved for the following reasons:-------•-----------------------•----------------------•-•--------•---••---••-•-•----.---•-=-•--.....••--•.....
..-----••-•---•-----------------------------•---•-••------------••--------•-----------......--------.....--------••------------•-•••----•••---•--------•-•----•-•-----•--•--••--•-•-----••-----•••-••---
Date
PermitNo......................................................... Issued---------------------------•-•••--------------.._......
Date
THE COMMONWEALTH"OF MASSACHUSETTS
BOARD OF HEALTH
Town... ................OF......Barnstable
...... ................................•••................
Tnrtifirttte of Tompliatta
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ) or Repaired. ( )
Steve Lebel
by.................. . ---------............------•------•-••••---••. --•-•....--•---•---••-•----••-•-•--•-•-------•....--•---.........---•-•-•------••-•-•-••-------
Lot � 6 a Black Oak Road Install�rarstons Mills , P•'A
at ..................•-•-----•----•------•-'•---------.....-•-------•.-------------•----•--•• F 5....•----•----..........-••---•--• -- /eri
has been installed in accordance with the provisions of TIirSgThe State Sanitary Co aspbed in--the-
le
application for Disposal Works Construction Permit 'o.. !...._.._.._....................... date .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. h
DATE...........................................
�..�f.... Inspector... .._._.!�t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
..........................................OF.....................................................................................
No......................... FEE..:'..-......-----•---
Disposal Workii Tons#rudion ami#
Steve Lebel
Permission is hereby granted-.. .--------•-•- --------•
to Construct
� ) or Repair ( ) an Individual Sewag�e Disposal System
at No
....Lot ,� 6 - Black Oak Road, 1V1arStons Mills , MA
.....................................................
Street
as shown on the application for Disposal Works Construction Per o.. ............. Dated.......................................... .
--------- -- ----
�_B� Board of Health
------
DATE..............................................................
FORM 1255 A. M. SULKI N, INC., BOSTON
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ry GAG 7 n,14
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NOSE 3
No.10951�10
Z` , FFSS/0 AL
LEGEND
EXISTING SPOT .ELEVATION Ox0 CERTIFIED PLOT PLAN
EXISTING CONTOUR o¢ M',�^s _
. FINISHED SPOT ELEVATION r
q ROBERTGi, Mid. ' /✓r
FLNISHED CONTOUR 0 RucE
8 L{fRED. -, IN _
i APPROVED , BOARD OF HEALTH-
DATE AGENT �No succ
BCALE1 j. � �� [DATE , Y 2_,,i
DGE ENGIREER/NG O '"2 r✓cJ I CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED JOG) a0.•••. .- 6 BUILDING SHOWN ON THIS PLAN
CIVIL LAND. CONFORMS TO THE ZONING LAWS
ENGINEER U E DR.my,
.,.,,' , ' OF BARNSTABLE , MASS
"II2 MAIN STREET CH BY � . .
H Y A'N N I S, M A$S.
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HEET_L.�OF
_ , SURVEYOR
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INLET .SEPT/G' Ti4NJ�CFT• _ l F7 O/i4M. C�SEE7�4B1/LATJON�
007PLE7'SEPTIC 7AJV K
IJVLET:O/STR/e!/T/ON BOX GRO[INO J 1TER TAQLE. / i ew yS:S
SECTION OF"..
,0&ZE .0.137 A&M.140N 6QX' .S' �o'F7 _
/JwLEr .g.4cN1nrG PiT O/.S
S3s � SE�/AGE PO�S'At SYST�J'yl p/ T�lel/LA?•lON
L�E.4C/' /Nh T '
.a L E '/.a" _ /=0" DIMENS/ON A—£__F'T.
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DESISIV CR/TER/A D/>yLE/vB/oN D- —F'r•
Nlli�fBER OF BEVROO/►!S 3 D/HENS/ON G.�FT.'•••
R8AGE0/SPOSAL UNIT J/o�✓e JF'O/L LOG "/L TEST
TOTAL E?T/MATED FLOH/ 3 3 u GAL. DAY SO/L TEST A/ $O/L TL�STo2
MV.14BER Q/= �`ACRIN4 P/TS / . F'tEY. SSA 4ZFV, OATF OF SOIL TEST
S/Of.LrACN/NG PER PlT Sf Sys T. ,� V _ 3 RESULTS N//T/VESSED BYR3E `/A Grp/3 .
d /3 f • / �' " "'► AWR COL AT/ON RATEe 0/ � � s s M/zv//NCH
:BOTTOM L,r�ICN/NG PER P/T SQ. Fr � o
TOTi4C LEACH/NG AREA - '` SQ• FT.. ° `��' `' '` I°ERCOLAT/ON RATE Ik2
RPSER{iE LEgCNJNG AREA 2 �'` SQ. FT.
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s � ✓ p No.10951 wp, wiz` EL DREDGE=ENGINEERING CovI/VG.
CL .0 7/2 MAIN STy HYANNJ9, MASS.
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JOB NO 6 SHEET�aF