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HomeMy WebLinkAbout0065 BRIDLE PATH - Health G5 Bridlc Path,1vlarstom Mills A=149-148 �I. i TOWNO STABLE dn LOCA`A'iC?N f t l� t' VII:.1,A rS /V l f S Fi,,b"SESSOWS MAP&LOT t�tSTR�LfiR`S N�+,tdlfi&�t�C11'd>~-Id0 s S'lr1C TANK CAg'.�►CITY LEAtG'J1�►.C1L1'T'1f (pia) 1 C P UDA,1'E C1l S'1[ 0.I�10E 1RA'x'i3, Sapsuatian -1AMaa (11 woon tea; MaxiimumActjustr!Cnauutl ty Pk�ivs,yr Supr,,y Vlc1'iwcl t, taiusg FAcilxtyy c�atfs exist o eita ac,wlthan .Qp feet of tea 09i facll�ty} sec t l c<yt V�letlan�!acid L ac tn�Ft i�ity(f in Weftdi exist � vitlais�:�Qa feet:a lapn}tits lac}lZry} )) n lac G na 0 _ _ M3 Commonwealth of Massachusetts Title 5 Official Inspection Form ' I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path ; Property Address Meg Johnson Owner Owner's Name information is c required for every Marstons Mills MA 02648 3-26-19 X. 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. A. Inspector Information 1 Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes ' 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3-26-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts f Title 5 Official. Inspection Form c-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments t ,.r 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town - State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or and all of 4 and 6. 1) 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: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "Cond iti o nal Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts 3 Title 5 Official Inspection Form I�• i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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 El ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2C18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 °'.. Commonwealth of Massachusetts .,yr' Title 5 Official Inspection Form i" ic► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_�; >" 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: t ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. []The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: - .+ Yes No , Backup of sewage into facility or system component due to overloaded or El ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 i Commonwealth of Massachusetts - Title 5 Official Inspection Form ws Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (coot.) . Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® , The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. j For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form ws i,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is Marstons Mills MA 02648 3-26-19 ' required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) . If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed .under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ' ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any-of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have lar a volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the'facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected'for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ®. ❑ Wasthe.facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the,Board of Health. _. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018• r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Ell 3 Title 5 Official Inspection. Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every I.Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, 6scharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑-Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts r� y Title 5- Official Inspection Form Ili Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203):• Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path _ J' Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system , ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1983 Were arriving the sewage odors detected when g g at site?ite. El Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r� Title 5 Official. Inspection Form .h.. i,01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 6. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass El-polyethylene ❑ other(explain) If tank is metal, list age:', years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to'bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top,of outlet tee or baffle 6'r Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leaklage. Recommend pumping for solids. t5insp.doc•rev.7/26/2018 * Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts 1� ,w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. _. ` 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): _ Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: � gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 01 8 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form i '�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >" 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and empty at inspection with stain line at 18" below inlet invert. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path r Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2&2018 f . Title 5 Official Inspection Form:Subsurface Swage Disposal System-Page 15 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. .,, 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .. _J6 U: 36 r .�p q&1 .: i e t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r-' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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: You must describe how you established the high ground water elevation: USGS and town maps shpow groundwater at 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts p� Title 5 Official Insp ection . Form 1 Iw,, l IQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Bridle Path Property Address Meg Johnson Owner Owner's Name information is required for every Marstons Mills MA 02648 3-26-19 page. City/Town State Zip Code Date of Inspection t E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate + 4 (Failure Criteria) and 6 (Checklist) completed Z D. System Information: + For 8: Tight/Holding Tank Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included r 1 r t5insp,doc•rev.7/26/2018 tt Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 LOCA :10 a SEWAGE PERMIT p0• x 0- E-� l- VILLAGE INSTALL I PS NAME 6 ADDRESS -; 1IR M, IP/ GUILD OW*ER d '® DA_TE PERM T I-SSUED J / j DAT E COMPLIANCE ISSUED- � 1 Cj) r' f c `a` No..D... ...: L. Fx$..... F��............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -....................................oP.....BD�.! .! T! ................................................. Appliratiun for Disposal Works Tonstrurtiun rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: u3T 4 . ........................................................................... ----.......--•-----•--•---•...--------•...-•-------•--------------•-•-•-...._••---.............--- Location-Address o�r�loUC . _---- - g.......--•------•-- . •--.---- -••--•---------••......................Owner Address W KA QS`TC�NS M.tL.� a ......................................... ........•-•-------------••----.... �?...................................... Installer Address Type of Building Size Lot.;;�dcPA o....... t V Dwelling—No. of Bedrooms................ .......................Expansion Attic ( ) Garbage Grin r�+ '4 Other—Type e of Building _..... No. of ersons............................ Showers — Cafete • P� YP g = P ( ) PrOther fixtures ---------------------------------------------- W Design Flow..................... gallons per person per day. Total daily flow.........._2,3z)........................gallons. WSeptic Tank—Liquid*capacity.LAVD..gallons Length......I....... Width.....5..._..... Diameter__.__:__-____- Depth._4-......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........1---------- Diameter.........3......... Depth below inlet.......6......... Total leaching area.sl°Z.g/........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.__R.,,5AAe!M.?VlL....... .f it...................... Date.... 1.71-1.3___..______..... Test Pit No. 1.... -------minutes per inch Depth of Test Pit...... -........... Depth to ground water_.. N __-. �T4 Test Pit. No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ c� ------••---------------------------------------------- ---•----.....------ .......................................................... ODescription of Soil-•------------ ��5£•......! N -•----..��v ......x ----------------------------------------------- V .......--••--••.....------•--•-----------------------------------------------•...........................-----•-••--••--•...•---------•••...-••--------------•-----------•--•---------....._•---•- W 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 TITIj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issu by he rd of lth. S ed.. .. ._ j ��� Application Approved By---- / --f-----------------------------•------------------------------ ._. ..... Date Application Disapproved f o the f oZt owing reasons:------•-----------------•----•--•----------------------•--------------------•----------••-••--•------.....------ ............................................•-----...------•---- \--------.._..------....-•-•--------......---------------•-•------------..............................-•-•---•--- ........._.._. Date PermitNo...................................` ................. . Issued....................................................... -- Date No... ~..C.:1.�• Fps.....�� ............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -ro"•'�...............OF....... .:`.�.r.f_ST A--....-..--...- Appliraatiun for Disposal Vorkii Tonstrur#inn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4-Q ........••-•----................................................................................. --•---------------.........---••-----------------......_...------..................---............ Location-Address or Lot No. c►.�A o L�5 plc ! ..........................................S w� 7.. n L__...----•-�'.�.a:.....:...------•-------•-------•-........... l - ------------ w ... owner N1�(�SiU�uS MILL -----------c . .................................................. --•---........---.•-------............------......----.. ......----....--...----------------.... Installer Address UType of Building Size Lot �':.` ......_S t ,., Dwelling—No. of Bedrooms.................�3.............._..........Expansion Attic ( ) Garbage Grin Other—T e of Building No. of persons............................ Showers — Cafet t W Other fixtures .......................................... w Design Flow.....................S ..._._....._..._gallons per person per day. Total daily flow.......... 2.................. ......gallons. WSeptic Tank—Liquid-capacityAMI..gallons Length...... ........ Width.....-``--....... Diameter................ Depth...4........... x Disposal Trench—No..................... Width.............�t.:.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..._...__... ___.. Diameter"^`" Depth below inlet....._?.......... Total leaching area.cg!� _.......sq. ft. Z Other Distribution box ( ` }��D�ising a ( ) a Percolation Test Results Performed by--- Date....!�1..�1-2 ................ Test Pit l Test Pit ,._.. :._._ 4sminutes per inch Depth of Test Pit .1¢--------- Depth to ground water-__!6`v`.... No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.___------------.---_--. P4 ........................................................... .......-----------•---------------------- ---------------• ---------- 0 Description of Soil------------- ` =```'- s !V ......--.tl v' =_-;TQ '✓ ------•--------------------------------------------------- x w 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 TITIE 5 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. ;ollowing Sgfied ---------------•-----•--- ..........Application Approved By.._ . '.. ..........................•---.....--------•--................... =- .. .Application Disapproved f °'the reasons---------------------------------•-----------------------------------------------.......---Date-----......... --•........................................•------••-------------•---------...----------.....----------------------------------------------------------------------------•---------------------•--._.... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (In ifiratr of f ompliFanrr PIT13)IS T-10 CERTY, That the Individual Sewage Disposal System constructed 400lror Repaired ( ) . by.... .:....°_.... t... Installer has been installed in accordance with the provisions of T TIF 15 of The State Sanitary Code/s3tescribed in the application for Disposal Works Construction Permit No ................ da.ted_. _ ..................... THE ISSU C OF THIS CERTIFICATE SHALL NOT B?CONSTRU A G ARANTEE THAT THE SYSTEA+I I FU TION SATISFACTORY.DATE........ ...... J........... P .............. .. Ins ect ...._........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................OF.......................................................................... FE>40................ ............... Dispo 1 Nor unu#rurtion rrutit Permission is ereby granted-. ------ e ' - to Construct ( r Repair ( an a Disposal System t •----...... at No....... ..:. ............ -- Street as shown on the application for Disposal Works Construction Permit No............... .: ated _ ............ ............................ .................................................. DATE. and of Health FORM 1255 A. M. SULKIN,..INC., BOSTON s p� `BOItT�O'LOTTI CON$7RUCTION INC, !sD88URl'J1CL 8EX7►OE :DZBPOSAL 8Y8.TEld. ZNBpgCTZON YOftx -Ovrat�'s•'raaer � . - hQat,e`�oLxZi�speGtion ___...._ .. F f 7 r t , ?ART:'A �5 CHECXLZBT' Chse t ,the tcllovinq ;;have been dons information vns re,ques ed 'of the owner, occupant , and Bo r `rHealth. < ti - r 2;one ,Ot{ the system comp0I.ehts have: been, pumped for at least two =end tirc�syatsm `has" been re.ceiv ng normal flow rates. during that psriod.<F ,Iargs� vbl'uYnas of water hays not b ',P, introduced into the uysts �'�cacently br as .part of ;this 11s built }plans have been obtained and e�ea �, Note if they i. . J vaiZable ta'ei�,ity ar dwelhi nq vas inspected :. f€;y s." .^:;ns .of sewage y The site vas rtr e:cted for.- si P qns of brea�rou U 11I1 a tste ; mi corapon�nts, excluding tfie been s'ita locate .c 1 ^ The soptic tank manholes were. :uncove red, opened , and the inter , the sapt3c tank ve's ,inspected for. .'condition of baffles or tees , �istezial; of co'nsti-uct:-ion,; :din►ensions', depth of liquid , depth o sludgq, depth of w� The = Ze arld ' hoCation""of the SAS=on the site has been determined o>s existing nfoziaation pproxiiaaaed . by non-intrusive method. . {The Za=cility cvner (arid occupants, ;if ;different .from owner; provided with ;:intormat-ion :on t?ie proper maintenance of ssDs . 141 r " K�, l .SUBSURFACE 'SEWAGE' DISPOSAL SYSTEM INSPECTION FORM PART B. SYSTEM: ZNPORMATION FLOW CONDITIONS 1!. -residential, ..: number of bedrooms ' num2er Of current. residents A arbage grinder, yes,. or no' S `laundry connected: to. system', yes or no seasonal_ use, yes` or no I nonresidential:, calculated flow: watez.`meter',.reidings, 'if :available: Last date of' oecupancy GENERAL INFORMATION Pumping records and source.:;.of information: Itlw �D recce .o UH - System pun ed as — --. P part .of inspection; yes or no if yes, volume pumped'' : Reason for pumping Type o2 system _ j�Septic tank/distribution box/soil absor tion s Single .:cesspool p ystem 01-Vre,low .cesspool ' Pivy Shared s stem y (yes or .no) (if yes, attach previous if any) inspection records, . . : ,...Other ;(explain) Approximate age of:' all components. Date installed, if known . source of informa. ion: Sewage .odors detected w hen. arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL. SYSTEH INSPECTION FORM ...PART B. SYSTEM .INFORMATION. continued . SEPTLC TANK.: ( O[[99(��'�) '(Iocate. on`.;site plan) depth below-grade.: material ,of,.:construction: concrete metal FRP other (expla r} ) dimensions: A. JAG X 5_411,k 6ff - _L .sludge depth 37` `distance`:from I. top of sludge to bottom of outlet tee or baffle " `scums thick-Tess `distance,.rom top of scum to top of outlet tee or baffle " distance_.from;:.bottom of scum to bottom of outlet tee or baffle Comments•, :(recommendation for. pumping, ;condit`ion of inlet and outlet tees or baffle!.I , depth of- liquid level:.: in;.:relation. to outlet invert, structural integrity , eyjtc�e'�,nce :ot hea aqe, recommendations. or repairs, etc. ) /C ; II .;::DISTRIBUTION:,.:BOX,...:., (locate .on site plan) y.'. depth of;:liquid. level .above outlet invert Comments r -(note if lever and dfstzibutfon, is( equal, , ev,idence of solids carryover, evidenee .`o! leakage in o- or out o.f box; ' reeomm ndation for rep irs, etc . ) o' � .� . Levee� q �a =levy _... PUMP CHAMBER:_-L '(J 'T ocate. on site `:plan.). pumps iw working order, yes. or no Comments not condition 'of;"pump ;chamber, condition of pumps and appurtenances , recommendations : for maintenance or repairs, etc. ) r SUBSURFACE SEWAaE . DISPOSAL SYSTEM INSPECTION FORM PART 8 . SYSTEM . INFORMATION continued :SOIL AB50RPTION.'SYS,TEM:. (SAS) (locate ;_on site; plan,.< if. possible• excavation not required , but may be approximated::by' nonwlntrusive. methods) ` It .not 'determined 'to be,.present, explain: Type. leaching pits and number /- /C00 ��� leaching ,charhbers and' number - leaciYYz�•c�'dY+e�.l+tsit anti i1liZdbe�' --- leaching':-trenches Axi"dr, length - l�achinq ,Lields -numE'er;; :dimensions - - .. ov�rtlow:-cesspool, number COmments.z. (no failure, level of ponding te conditionof soil, signs .of hydraulic co dition o ve etation, .recommend tions for maintenance or repairs , etc . ) GYM DL - S - CESSPOOIS (loca.te on..'si_te plan) number a nd'!configuration depth top of ;liquid ab, inle.t invert depth of solids Thayer ----. depth o scum'. lbyer:. ,dimensions= of cesspoo — aaterials, of 'construct on ---- r;f nd cation of -gr,'oundwater inflow '(cesspool must. be pumped as part:: of'`•insped. ion), Comments:::`...,. (note �ondition ,of `soil; signs of hydraulic failure, level of ponding , condition ofVegetation, recommendations for maintenance or repairs , etc . ) PRIVY-s Nv --- (2ocate on:site: plan) of construction dimensions...- -- depth ot,;;solids (note° condition of soil, ,signs of. hydraulic failure, level of ponding , c ondition of vegetation, recommendations. for maintenance or repairs , etc . ) 8UBBURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART B. . SYSTEM INFORMATION continued SKETCH OF; SEWAGE:,-DISPOSAL; SYSTEM`: include; ties '.to* at least-two permanent references landmarks or benchmar}:s locate all wells within 100 ' 0 3q DEPTH... TO GROUNDWATER. depth.. to groundwater method of :'determination. or approximation: • J' ON n94�• /'O - F t u IiN .. 4 Y • �/ { ;SDBB0RF710E :,SEW7IQE DISPOSAL. BYBTEM IN SPECTION 8PE CT IO N POM. , .�. PJ►RT C . ' 71LLDRL CRITERIA` x 1nd3Catsyes, no, ors not determined or; ND) . Describe basis of .�dstesa�ination in all instances. If "not determined." , explain why not) ry Baekup oLFsowage into facility? Discharge or ponding of effluent to':'the .surface of the ground or = surlace,waters� Static liquid level .in the distrbut ion. box: above outlet invert . a � . id .iie th` in cess ool-> <6" `below invert` or available volume< 1 2 da 4 1 ,. p P flow? .Required pumping; 4 times or: more . in. the last year? number Eof t :mes-;pumped . ,, Septic tank is metal? cracked structurally unsound? substantial infltraton ' substantial exfiltration? :`:tank failure imminent? Is any portion of tte cesspool * or privy: V.below the high groundwater e.l:eva ion? -5 within 5`0 feet of a :surface' water? ;wit2in 100 feet of a `surface. water supply or tributaryto a surface water supply'? hin a Zone I' .of a ;public''well? ,within 5.0 feet of a ;bordering vegetated wetland or salt marsh (cessp.00l8 and;privies. only, the SAS) ? within 5o feet of a,.private water supply well? than 100 feet but greater ,than ,5o feet from a private water supply vellwithno acceptable waterquality analysis? If the well has .0on-nana, yze.d to :be .acceptab`le, attach copy of well water analys for coli.torWi!, acteria, volatile organic compounds, ammonia nitrogen end nitrate nitrogen: l: N �E ? 1 X Y BUBSbRYACL SEWAGE 'DISPOSAL:_'SYSTEM INSPECTION PORN ,�.... PART D. CZRTIYZCATION W. �.� Nams ,ol .Inspector Company: Name k g bu( Conipanyl; 7►ddress:'7Go Le c/Wit 0 "'''� mortification Statement" . Z Cert .ly, sthat ,I haws ;personally,. fnspected the sewage disposal system a; dddrsss,,and that ;ths .information: r.eport :cl is true, accurate and cv pr�t��"aa ,�.f 2nie tinte:_of : inspecii6n. The inspection was performed ar <: any_ Yscommendat.ions, rsgardinq upgrade", maintenance and repair are eonsist'snt'with`.my training :and experience in ,the proper function and manitenaner:oon sate sewage disposal systems. 1 I ave,:h ot;nt.o und an informat on which hiy nslcates that the systems f , . . to 'ad�quately protect public health,.or :the environment as defined r: #1CMR1303 ►ny failure criteria not evaluated are as stated thiMY71 iTO cjtZTLRIA.,settioh of; this: form. dQtermined that-ahe `:system : tails to protect public health the �nv�frorin►erit as .defined::.in 310: CMR 15 . 303 . The basis for r_hiF. d�tsrmination` as` provided .din':the. :YAJLORE CRITERIA section of th i f o{M. In�pector'c:Signature Original to.� system:.owner; �w Copies - ` Buyer ;�(if applicable) wpproving `autihorty`' 1 SECTION SEWAGE SEPTIC TANK - - •,D,,BOX - - LEACH r� ( T', rI, �Q`T• ,r ` TOP OF`FDN (• �'t•�� (MSL)et „2"OF 48TO 4:' • WASHED STONE • �� M/ `c o sue" ,' ; � �'� �ti� I - .i+ !N' OUT- !N OUT IIV '1j�� ' /\ yr • Gs7[T:A TIC t\la9S0l�LEV. NK 4 - y+ ELEV. ELEV. . Co•O' c$'t ELEV. ELEV. ELEV. Got �iD 1O"�* Qv 6'-•{).4 �i ` �j� - n.. WASHEb STONE ry TEST HOLE LOG TEST BY R.�,tfZl'yAa.d`C, •Ts- ,. �AC^C�@,`•! ?�.a.�. �i' � � `WITNESS 3 TEST'DATE Cof1 DESIGN BEDROOM HOUSE ' T.N. ,w 1., -lz.m T.H. # 2 I G7G e� ELEV. ELEV. NO } Z, DISPOSER DISPOSER PERC RATE: _MIN/IN. FLOW:RATE (GAL,:/DAY) 3Co loq;c� SEPTIC TANK 33o G•S1= �d REQ'D SEPTIC TANK SIZE . - , , ���® �` � - < - ��^••' •. ' • 'fig LEACH FACILITY, co,4e ., �awyD, SIDE WALL (t-s 1 = - G/D. 3'tto C�T:P+*re'�. .ti}• c+t•+,+` BOTTOM .gh ( !.� ) �a©.ZG, G/D. ;S tF• J - = i TOTAL nl.l ' = 4-2-1t7-G Wt7. USE: C� r.►�:. LEACHING �\T � t IGS" - G, Cat d��t X Co GIeL'{'C. I.)/ 1•A SC'G>b• Iz I WATER ENCOUNTERED Y NOTES: (UNLESS 'OTHERWISE NOTED) • ', r f ' 1. DATUM(MSL)±-TAKEN FROM ` � QUADRANGLE MAP ! --�_ , r AVAILABLE 2.MUNICIPAL WATER �,- ----•-- -.,._.». _ 'OF •� , 3• PIPE PITCH:,,l(,"PER:FOOT I A _ 1 c> ��� 1 0- !� 4. DESIGN LOADING FOR ALL PRE-CAST UNITS:•AASHO- -44 q 5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. �� G —DI.S7ANCE*AS CERTIFIED 6.PIPE JOINTS SHALL BE MADE WATERTIGHT IAM y• !' , 7.CONSTRUCTION DE PAILS TO BE ACCORDANCE WITH COMM.OF MASS. ti ` . ' _ I HEREBY CERTIFY THAT 7HE,BUIL'fJIN.G M PLf�N STATE ENVIRONMENTA4 COQE TITLES itAA ' SHOWN ON THIS PLAN IS r_OCATE=D ON T11E 4.1 •< SITE GROUND AS SHOWN,HEREON&T11A`I I I' LOCUS: ^, CONFORM TO THE ZONING'9Y LAWS OP+T1 tE `i /A O ,i `w t - � �F, ♦�y P�'i S: ��tt' . OP.THE. .. y , `��h,�TC�Al$. � n�\1 I..�.�. Ekj ? TOWN OF t s° R G. GINEER WHEN CONSTRUCTED. DATE • '` »..c 'T A,O tf. - ►'- , 3 a?��,,,C' tOtn Tlif z PREPARED FOR: e' �...,..,.,.,...•. CYVILENGINEERS 1 ' .AND SURVEYORS4`_ _ ; BOARD OF•HEALTH• y -'.REG. +v (EXISTING --r-•' ,' — } }•. s *LAND S RVEYO GALE eR CO 1 G> b�r CONTOUR. a�VED — - A.1 ./+i �Q,`v MA Ya mo, h�t qri® ns MA tu R S Ij (PROPOSED), ��u-v� - •=.�..n�+Tr.. x- r ti a f•. , [SATE �*�'�- + t