Loading...
HomeMy WebLinkAbout0207 BRIDLE PATH - Health 207 Bridle Path A= 125 —053 Marstons Mills i l� Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ; 207 Bridle Path Property Address Brian Lawless Owner Owner's Name / information is Marstons Mills y MA 02648 11/21/19 required for every 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 filling out forms A. Inspector Information 61,o-1g313 on the computer, use only the tab Richard T. Johnson key to move your Name of Inspector cursor-do not D &J Environmental Services use the return Company Name Y 10 Mt. Pleasant Street Company Address Plymouth MA 02360 City/Town State Zip Code � 508-735-8740 S113545 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11/21/19 pectors Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form r, I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: I 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c� Commonwealth of Massachusetts 1. Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path v Property Address Brian Lawless Owner Owner's Name information is Marstons Mills MA 02648 11/21/19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2 System Conditional) Passes (cont.): y y ( ) ❑ 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 a ) /L pass inspection if(with approval of Board of Health): '" !� ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. t 1 a. System will pass unless Board of Health determines in accordance with 310 CMR N 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 207 Bridle Path Property Address Briar. Lawless Owner Owner's Name information is Marstons Mills MA 02648 11/21/19 required for every ' 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: ❑ 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I?, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 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 flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: PresentlyDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Bridle Path Property Address `Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. Cityrrown 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.): N 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: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? ; Reason for um in : P P 9 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 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: 2003 per as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: <1feet 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.): joints structurally sound, no signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F I 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: <1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Dimensions: 1000 Gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Field Measurement/Mfg. Specs. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Sanitary tees in good condition, tank structurally sound, no evidence of leakage. It is recommended that system be pumped regularly to extend life of components. This report does not guarantee that system will operate properly in the future. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Property Address p Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Traplocate on site plan): ( P ) Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 1" Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �n ►p Title 5 Official Inspection Form tp Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 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 01, 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.): Box level, distribution equal, no evidence of solids carryover, no evidence of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r Commonwealth of Massachusetts �T Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Properly Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. Citylrown 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 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions.- El 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 T p Title 5 Official Inspection Form pl; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Bridle Path v Property Address Brian Lawless Owner Owner's Name information is Marstons Mills MA 02648 11/21/19 required for every � 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.): no evidence of hydraulic failure, no no damp soil, normal vegetation. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. Cityrrown 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.): I 15insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstens Mills MA 02648 11/21/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons:) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: [hand-sketch in the area below ❑ drawing attached separately .i 33' so 3 32• y3 �N (OD� y \P 9 I�P t' . a 10 tRz•3n3 Title 50ffi" F— MWW System•Pepe 16 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 15 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207!Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. Y P Cit /Town State Zip Code Date of Inspection a D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 7.7' below bottom of pit. 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: Obtained from site observation, visual elevation, Ground water adjustment= 3.3' Bottom of pit is 9' below grade. 7.7 ' net depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 207 Bridle Path Property Address Brian Lawless Owner Owner's Name information is required for every Marstons Mills MA 02648 11/21/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 LOCATION SEWAGE PERMIT NO. VILLAGE 3� M i'l is IN.STA LLER'S NAME A ADDRESS Oabe2 i OUK Co B U R D E R OR OWNER 0 A T E PERMIT ISSUED ,? DATE C0M.PLIANCE ISSUED G � i _ 4• e A � No.. -...... 5:2 Flcs.....°...`...�.... THE�C-OOMMONWEALTH� HEALTH � TS !D /'°p . _ ...--.....OF.... ........ .N...J L- -------------- �� Appliration for Uhivoiial Workii Tomitrnrtion Vanfit J/ Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal syl at Loc ti n-Address or Lot . caner /'� '— — Address l8 j .... _ -.� 11-!.�• fl ................................... .......••-------- lz Installer Address d Type of Building Size Lot4R_ . ...,5J-----Sq. feet U Dwelling—No. of Bedrooms._......... _ Expansion Attic (IV Garbage Grinder (,( a �i... ----. No. of persons....._.__.............. Showers ( ) Cafeteria Other—Type of Building-/ ( ) Other fixtures . = -------•---------- W Design Flow............................................gallons per person per day. Total daily flow-------- ....................gallons. WSeptic Tank—Liquid capacity./Q44allons 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. Other Distribution box ( ) Dosii t ( )// `~ Percolation Test Res is Performed by-_ .:____ �gt_i_!�.?...p............... ..... Date.....3 -� � 0a Test Pit No. I....._.. _.__minutes per inch Depth of Test Pit___. _. -�...._ Depth to ground water.�.�..d..."` ...�Alt- (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ) Description of Soil ...f l..`--j-------•------------- W ---- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•-•-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------•--------------------------------------------------..........--------•---------------------------------------------------------•----------------..................... Agreement: The undersigned agrees to install the afored cribbed Individual Sewage Disposal System in accordance with the provisions of TIT iE 5 of the State Sanitary C e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by the health. - T�� �7� Sined.. --•-------•.------.....�---� -----------•• .............-------- �� .......•/ Date Application Approved By...... . •. • •. ...•... Date�j Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- ----------•-----•-•-•----•••---•---••••--•-•-•---•---------•••••-•-•----------------••-•---••---.........•-•-•--•-•••--•-------••--------...---••----------------•-------•---------------------...-•--- Date PermitNo......................................................... Issued-....................................................... Date No............. _.. F.Ra.....�...._............ _ THE COMMONWEALTH OF MASSACHUSETTS EOA4R F HEALTH � z ApplirFatiou for Uhip a al Works Tnmuurtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy l � - !7 ..... 2._� � _. .;. ........................................... .......................•........---•-•---- .. F . �L.oc Addres r Lot 1 Uz ...... .- _ tAto f C.2_E.. ....-- .............. .� Qwner l� -- Al t - Address Installer Address Q Type of Building Size Lot:�R­)t.h.S�J_.....Sq. feet Dwelling—No. of Bedrooms........... .. .......................Expansion Attic Garbage Grinder OV6 Other—Type of Building/.�._. __ _._.. No. of persons..........3.............. Showers ( ) — Cafeteria ( ) Otherfixtures --------"---•----------------------------------------------------"--------------------- ..............................=----------•----------"-"""-""• W 1 Design -Flow............................................gallons per person per day. Total daily flow-------- S._ ........._............gallons. W - Septic Tank—Liquid capacity_104allons 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 ( ) Dosi t ( ), _ Percolation Test Res is Performed by. .:___'-. �a+_ �'. ................Date_. _."._ ..............+� J 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........................ - _ O /r e' 9 .C.._._ '.. 'T.ai� �V llrr..'�2... Sir'•.utr V Ct .�.................... Description of Soil....U/�' j U .........................K........... .... .--0--`1 ....-�.-�1 ti d--- ---------------------------- ------ •"-----"--"•. W --"------"-----------------------------••---•---"•----•"-----------"---"--------------------------"--•-"---------------•--------------"----"---------"•----•"-"-----""""•""-""---------"-...---•.----"- VNature of Repairs or Alterations—Answer when applicable............................................................................................... -------------•------------...---.._..-----------•"-•-----------•---......--------------...........•----------"-----------•--------------------"------------•--""-------------""...---•----........•---"- Agreement: The undersigned agrees to install the afore cribed Individual Sewage Disposal System in accordance with the provisions of TIT 1 E 5 of the State Sanitary/C de— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has �Jee issued by the health. r ........., ri ! e/ Signed.`_ `..........••-- --" ...... """'"'�=''=='----------------- -------- -Date• �- -__----------------------------- ------_-�' -------- Application Approved B PP PP Y----•- -• t�-�•- - -� Application Disapproved for the following reasons:................... -------•-•••-•............................................""•"-.._.-- Date------...... ....................•---"•---"-""--••-------.-""-•-•"----"---...-•----------"-------------"-----------"...---------"----"------------...."""------"----------------"----"---•-•""-•--------•""-------•--- Date PermitNo...................................................... Issued....................................................... Date a THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH ...............:....... OF.....�.. .: .� -! .A...f. ! .�!:.. .�................... TntifirFatr of. Toutpliunrr T�IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by••--••--•-._. �- : 1 �' --- ---- -- - -------------•----------------•-- �.f If ffu at ..Q. �� ' -f . - r i rcaues --_ -)..... ....................-------------------------------"- has been installed in accordance with the provisions of TI 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No_______________A_.....__..._.. dated....._. . "..?..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST RUED.-AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �/i�'D tDATE...................?r/.-----....l f--------__� ....-••_.. Inspector........1 ---- --•------------..............---•--........... 4- THE COMMONWEALTH XD MASSACHUSETTS BonOF HEALTH 7 +.:..L.uU... A..........O �� .... :.�.... _ ... ...................... r- No..........13. .... ........... R151l Fat. nrkli Towitrur#iun rrutit Permission is hereby granted ' T............. , --fok •------- to Construct .. or Repai an I;nd iividyal,$�ewage Disposal stem at No...... /!� .L3 -... •j...J....-........... jZ `�. bkj Str as shown on the application for Disposal Works Construction Permit No..... .............. Dated.._.-�"j�:_.!..�.:-.............. f- DATE......... �' •--••-•-•------------------ ............... Boar o ealth FORA 1255 HOBBS & WARREN. INC.. PUBLISHERS r�tC liiti ✓ a j[�x" wZ 4 \x* RY e'" l gi.`�Y t S�� /1 � �`! a .F t '' ; �+. .:.. -f'�,' • ;:'� :,•+v.. � �' OY �r r -..� �•r,>i-r' ,• ' '� ,� v°�8-. r r eµ• a ✓w... s y a R e f c •+ { +' / ,ti#, r< n@a X i'^ 1 k,�• ,•^yfi' „tr.. r r a^ 4 : a ,s Ar y if y a. a, `� t 3 [ � Yryk H [ 3' L y .Y l� N_' V S t' Y • { - ` �1�•' i �"?, 4so ! "'e 1, ��, RLYs r" iE rw•g3y�v,. 1+4 ".t ,f k r:�.;= r5 r'a.- f t .,ar , ' q,t� rr `L 'rCi •ta �.kt�, ��*t,}" • br y .!r. �1 ,n,y. i 41s' rV �3 it d ' s7j " � �r ,.t4fx M°' :.;} 4 �I.R/`S/a� y Z a a Fy,r * Sy 5' { r. }. r,# �'•. �l 1 r `rr r�w . .` M yb 7 ES t A• a {:.'d -e+{ ., r - .Yi. ['N `�� } -' �{ XS 'rd` S +� a, ��r• ,. Y ..ye E 5',{ •1. � , r _ fir,, aYih is ttf t. O'6r_ s• S S [ >t „.` ' ,+•��r1 .r 4g-1,t� t Y' \\.' 'Y ai•' �� U K t'. L 7 r ,„ d S..n� r Y y4,3 V� i� � y +.._ /���� �1 � �' 1 ' t x .` Jfy Y*.�� 1 ,. 4 .}' . t r- 'a, f' dry,,r s yam/r9 '4; ,.q •) -r.'- �r� f. R. , - 7 ' - s - 5� '" J ^.� � ; 1'� + YjF •,1 S t• / '� a jf�v:�. j , x It + {, _�P. i x ' I ,,M1i * afill- 'Id �..s �1{"/�r1 •.,t" .O�i• a r .,�' a '� 3 , « .,Zy !�j �" r�► �:'w-sa �'''�' 4 rM r °'J' ��k ;� �"� „'�( ? r�# M k + �rl r � 4<� r� '` � f� �'s•E�Ssc7,X ;�'^ {,p' r iA�1 � / _��•F * \ �;-* .j K � } '� .. r�• '.•a a �, H.,•t: ^}' �: �t� ��` ��. \ ?` � � Mt^ t'.� 4 1q R � � Ali � itl } i �•; }� 1 _.tF.�w ('„\a e? V• •''O 1 V fL'1 .p^ 1.{y ,. _ 'd• A w{' �} t *f + +\ Cv 4 4 IQr1 �n ' �Y f e4,17, f'at �� �� r� �( !`�', a •rid w r4 � t � •' � ,� 1 a,LL n r � #c � �- f ;<k•�� �t rr % Sr'. �a�JT� .r r , r .. «),' �n .a �� Jr `•Y' [f� E,' �a v �� � a'X � } f i I e i= TS✓ r }^ A ti T :. r P, �.� Is tiryy *y •r. Sri t�t i � r,€1„� ', ',n., � �r :' ,�+ r n � � r,r ,}• �, o S' s�k r� 1 sX F.4rS sl 6 # Mr Tin 1 yg tr F.r ^ t� r m t A ; y wit TC f � ��'e t'' x 'fy, [ rF ' r o e�.a,r {7 •y�-,, � r�..;. � �! �=.� ,>,4, .li:\; . ' R � h s �r °� J � !; E.-��r +�,, ltt., .'i �4 caY' w.�, �] 31} s •f 2`' r•Y TI6'"" WTI'l^+yy`)1 « �' �• A-� .Y d,x,..�_w.�'V /'..rk NpY �9r`t,. ;v � � ,) bi' i � r �' � [4 �� �3v y jY °! •' ��y y , , „ lip t �i e I°!' [�,a x ��'" 'v v__ _ _ �' � 5 QQ ,„ F K �• F '� � '� 1 ;3 P .. r a.�' '�� .� ['�' i�T ��. t' `. �''ri \�t� �� #.� :� 7S 3 ,`r �} ;'� 'fir /r t':� i x ,.•y = i [ � '`1 � ' . ,` c: r *,t ksg.t Y t g r x d r � -Ex �•'-'tiS`y f-�,t;'`e�+, r r {YN ��. ✓a #^`�z_c ^2r'-`.t R '". ;. 'r• _ _ — .�,t,_ �u-- - ,: 5 6 a R ASS k�,.�•� h '`6 m ` 5�:. [ 4•a i s i r$ry. #.4` . . t. ' .� d ..f >f� t F F -; .dxt�'d�iF' �"^y'�C.y4�.SY�. t' l�Y��'� �� I' � }.��'Y� N ' i IF� �. {H r1� � t ✓ � � �q'xT3�y�' IfL'�A�C�` Y �3. a �?,� a dx:�+r�\' a•§' ! c 'gyp "il. . f .,� „) * � Z>f' ,Z"..t �� �.t J' �"'7 .'€ :6.t; . .;�tdp °; 'ty.,F9 :r u3 i h r�r #i. > r ;•Y �-. ',.4 �i 6R to � CER0 Ix t NA, SPOTz41ELEVAT'IO -... c( x '' 1FIfD r r PLOT PLANS � .,3 J, L /; TrF1�t3s CON�'OU y "p *� • a y r l- cl1 i�" *F, i=it ESPQPT irLErVA .t.ON, �s' ` � t' �`�'h � � A tC.0NTOUR p' 119A)� H erg/ :.t i J M- y' 14, t ,� 4 •u .. Ali BUrSKIS F `F BY Ap" _n G w /s�_�' l a Nc2162 (9- i t t k, ��N �„ .0 z r* $�s V RDf* Vi„ IT� Alvin � x �90�. �I AS J � MA AGENT, SCALE DATE+ /y�ly�' i Dj " IICiIIVEERl�11G0 /N; , 5 ,a �,CLIE �v �a I C RTIF•Y THAN THE PR P�4SED r a. � a ac J08 NC. -770 •SHOWN QN THIS PLAN , ..• S''{:RL1AF c 1' y . -. . rO, R' INS TOTHE ZONING N CON lAIS ff UfY DR eY pFR STAB LE' MASS. °r ,p' . p �• 4 i ' ' � dufAir�, ! ;< ZIZspMIN S1` ' CH. BY M UTH MASS.."'t HYAN(�Is T ,Z ,., . ,r �. SHEE OF p T a ` RE LAND SURVEYOR , e r t F Nlc 7$J,. '` •°' iav r'�:..e- '/ {r"'' :Y 1 '^�c xrbg;.. , � - .�.:. ,�-•q.t... � 1...yk 4 .. .� >.;�• 'r' -n ,c.•.,"" T ..•� a a,, �,v .�-'�' *,� sF�ylF >.$'5-y M ,.� . �c 4 k' ti e .. � " r., ,.. ' k' L _. •f G� . E/A7-/-/ERp T/¢E a FP7 7AIvy(< OR /2'/BEL0J-V /O FT: M/M. `rh'.�i DE, fa 24 O/A M E TER .CONC,�F TE COVER _.�_ SJNALL e.E 9�OuGNT To G/gAoE ._�.-ai✓ FXTR.a " ,� CONCRETE i 9'PVC P/Pe. HEAVY C-A ST /?ON CO vER. SNA L L. (3,E L S E.0 Y8"PE.Q ✓EN/A y A, CL EA/V S'A/V,O 'Y � --_ _tom_--.___��. U LEI�EL � � . • 7 + 4" CAST- -.__-- `,•. r. o{� ' "LAYER IRON GAL. ° .: 1 • •I • . • . • / ►a v �' SHFO. STG/YE Vo"PER —r. SEPTIC TANK ' D/sT. i 4 W A C A — • • •, • • • • • / 1 ,v r, d C o BOX • o � ov • 1 � 8 • • • 1o°per ' N o p p Ail ;;- ( ., � ' v n o � 1 1 •EFFECT/VE 1�' - �. ° ' • • DEFT// • • 1 '3° 1 WAS.NEO STONE ^ c. 1 • • • • • • • • ( . A O o u �_�' a'. ._ � I � e oho Sd I 1 •� • 1 • • • I 1 rQ5. o v o d 1 • •i • o. • • • • •" p p•p PREG45 T SEEPAG E I)V eRT EL E SIA 7-1O/V S v 1 • .: • . .. . . . 1 1 a o f P/7 O R-EQ U/V. /NYERT .4T dU/LO/NG y13,0 FT //�ILET SEI7T'/C TANK 4 '•S! FT 1f� FT C(SEE T�lfi[/L 4TlON INLET U/STR/t9UT/D/V BOX 9�' FT. GROvivv W,4TER,TABLE SECT/ON O.� OVT[ETD/STi?/BtlTiuM BOX 6• .FT. SEWAGE L7/.5PO5A L SYSTEM /NLETSEEOAC�E F�/T �_6'�,�fT 4EAC/N//VG PIT TABULATlDN FT 3 D/HENS/aN C_�—FT d19. h NUMBER OF BEDROOMS G.4R9AGED/SPO>AL SOIL ?EST - . TOTAL EST/MATED =Lo�✓_3. U__GAL./0.4!' SOIL TEST / SO/L TE-S7-#2 . iY411"8ER OF SEEPAGE P/7-5_.' /_ _f^ELEY. a0.0 . r.-EL`cY.__ ,OATE 0.= SOIL TF_ST �•-�`i t�/ /1�7 S/OE LEACH/NG PEK P/T _/ c _SQ, FT. I� RESULTS G 6UTTOM L:-74C'YING -EK P/T_?G SQ. Fr. COLAT/o,v RATE-- At I!O.._.._ M//v.I/NCH TOTAL LEACH//YG AF1EA _�(v G_SQ. FT. iv, So •a't+,�d F'ERCOL.4T/ON RATE RESERVE GEAC',//NG AREf►_���SQ.' FT. Vie P., �_ L 7` '3 ,�f,Jae <.1 BUNIKIS 90� GIST��;� FSs�ONA��- v y EL DREDGE ENlt/VEER/NG CO.,/NG. ,. ? N 33 ND. MA//V .ST. y . 71 /VO GROUND Y1i4TER'ENCI IJNEP HYAA � MASS SO'YAR7!9C►tITI'/, Ms1S _ ��_ ` cp b ::r x r ;a r.' `} ' � .s: x yam': ✓ 8 /VO�l?G9_ $f/E/�TJS01— uw•e iw.Q - :y. w-..a - .. .. �,q. n :�'— - _..w-'�.T—_-k . . .. i 4 .a•�i _ :'§}, �_+-'.... -w .91i � ." •_ - _ �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name / information is 207 Bridle Path Marstons Mills i/ MA 02648 10/2/15 .0 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in arty way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 2—le the computer, use only the tab 1. Inspector: key to move your cursor-do not Dan Speakman use the return Name of Inspector key. �� Speakman Excavating LLC ICI Company Name 15 Speak Way Company Address I Harwich MA 02645 Ciry/Town State Zip Code 508-432-5565 S113817 Telephone Number License Number B. Certification j I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ©G� 20 oS 5nspe ors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is 207 Bridle Path Marstons Mills MA 02648 10/2/15 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any informatior..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 2" 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is 207 Bridle Path Marstons Mills MA 02648 10/2/15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Bridle Path Marstons Mills jl Property Address Joyce Schurk Owner Owner's Name information is 207 Bridle Path Marstons Mills MA 02648 10/2/15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sev;age 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 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner owner's Name information is 207 Bridle Path Marstons Mills MA 02648 10/2/15 required for every 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 _ie SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface.water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considereo-a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is 207 Bridle Path Marstons Mills MA 02648 10/2/15 required for every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping inform^tion was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments H 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2013-11,000 gallons 2014-11000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current 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 ❑ No Water meter readings, if available: , t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Y Title 5 .Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M . ' 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the il-_spection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Insipection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: _ ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 4" Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 207 Bridle Path Marstons Mills Property Address Joyce Schurk Y _ Owner owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 page. CityrTown 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 30" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 4„ Distance from bottom of scum to bottom of outlet tee or baffle 14" 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 in good condition, no sign of leaking of backup Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 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.): i plan):Tight or Holding Tank(tank must be pumped at time of Inspection) (locate on site p a ): Depth bellow grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M > 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and aistribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no sign of backup, some deterioration Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length. ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1 6' pit with stone, water level at time of inspeciton is 3 feet from invert of pipe and has appeared to be within 12"of invert and some point, Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Fo=Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is required for every 207 Bridle Path Marstons Mills MA 02648 10/2/15 — page. CitylTown 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 Pr lis �N /Vy 3 u \1 tit V 0 Y A t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 115 of 17 Commonwealth of Massachuseds Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owner's Name information is 207 Bridle Path Marstons Mills MA 02648 10/2/15 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet 7 7 �SFI �a� P� Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of desii n 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: 4PWAJD n 59 &' X, �oU Aj'0 e-c.G4 2 c0'_j;--ov/L 39 20 ` D/r'l'e-2 C--ACC- n-a".7 oT' PST iS 9" ��a-- 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 i q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 207 Bridle Path Marstons Mills Property Address Joyce Schurk Owner Owners Name information is 207 Bridle Path Marstons Mills MA 02648 10/2/15 required for every page. City/Town 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 I t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17