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Commonwealth of Massachusetts
fi Title 5 Official Inspection Form
HI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.;> 149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2019Date
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i)l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd `
Property Address
Patricia ButlerR�r
Owner Owner's Name
Information is r.D
required for every Marstons Mills MA 02648 3-25-19 ='
City/Town State Zip Code Date of Inspection rt '
page. I,,.-n
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):
I
i
3. Pumping Records:
Source of information: Owner--pumped 5 yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
oaf�- 15 v
Title 5 Official Inspection Form
i-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
:Te
U0
149 Camelback Rd
Property Address
xy
Patricia Butler
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 3-25-19
page. City/Town State Zip Code Date of Inspection 1
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 67 (a 4,(Q
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 S 13971
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 15.000);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
3-25-19
I spector'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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts '
Ell Title 5 Official Inspection Form
C�'i: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete'1, 2, 3, ors 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 "Conditional Pass" section need to be
r
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):
Y ,
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
i
Commonwealth of Massachusetts
ra Title 5 Official Inspection Form
tal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r a
149 Camelback Rd `
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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 ❑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 ON ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
r 3, Title 5 Official Inspection Form
iw,,
iIr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>" 149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
[]The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
MI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
i ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) ,Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
s Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills f MA 02648 3-25-19
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?
® Wasthe facility owner(and occupants if different from owner) provided with
11 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
IN Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is Marstons Mills MA 02648 3-25-19
required for every ICI
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): 2
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, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
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
s Commonwealth of Massachusetts
3 Title 5 Official- Inspection Form
14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
s_ ;> 149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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: Owner--pumped 5 yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
NI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
page. Cityrrown 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:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of const:-uction: '
® cast iron ® 40 PVC ® other(explain): Orangeburg
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
Title 5 Official Inspection Form
R,
4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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 ❑ 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"
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 leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
r
Commonwealth of Massachusetts
a Title 5 official Inspection Form
l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
page. Cityrrown 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 tcp 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 i nspection)(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
,w Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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
r Commonwealth of Massachusetts
Title 5 Official Inspection Form
1.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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� ,w Title 5 Official; Inspection Form
i.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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 30" 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 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
C,
Title 5 Official Inspection Form
w
• C-► Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M;C
r
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Ile,.., Commonwealth of Massachusetts
1� 3 Title 5 Official Inspection Form
bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`�
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is Marstons Mills MA 02648 3-25-19
required for every �
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
. k
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7►'
`5:
f 3
61Y.
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
Property Address
Patricia Butler
Owner Owner's Name
information is Marstons Mills MA 02648 3-25-19
required for every
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)
i
® 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 show 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
r� ;w Title 5 Official Inspection Form
hh Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
149 Camelback Rd
J-
Property Address
Patricia Butler
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-25-19
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
s,
For 15: Explanation of estimated depth to high groundwater included
i
t5insp.doc•rev.V26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
T WN OF BARNSTABLE . �
LOCATION 3R CdlV e Al SEWAGE #
VILLAGE,I 5(1 ✓ 112 ASSESSOR'S MAP & LOT -/r�
INSTALLER'S NAME & PHONE NO. 11,14,4 1
SEPTIC TANK CAPACITY �lJUD
LEACHING FACILITY:(type)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE
BUILDER OR OWNER el Jll 611'5 4,0111 /!fl JU• �y1�D /�'
DATE PERMIT ISSUED: 6 �G
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�,
� �v�
� � a Q
�(�..��
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��,N � ��
/� (/sue- ��� Y
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N.......?
Yuic............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HIE-ALTu
OF........... .
Appliration for Dwpoiial Workii Tonstrurtion rantit
Application is hereby made for a Permit to Construct 4T or Repair an Individual Sewage Disposal
System at:
......................... Z4.4—i...........
Location-Address
...... r7 ----------
0 �/A4&e so
jo.........7 W.A. dress
TV............................
.............S/ ...... ...................d
Installer U Address
Type of Building Size ..Sq. feet
lle7
Dwelling—No. of Bedrooms............ ..........................Expansion Attic Garbage Grinder
Other—Type of Building No. of persons........ Showers Cafeteria
----------------
Otherfixtures ................ .....................................................................................................
Design Flow...............;��...:::--:::..--gallons per per dn. Total 04Y fig*........ 9.....................gall 's
W.gallons X,
9 Septic Tank—Liquid capacity/ Len;7.fe.... Width— Diameter________________ Depth__ ....
Disposal Trench—No..................... Width.................... Total Length_____.___-_ ... Total leaching area....................sq. ft.
Seepage Pit No-------I------------ Diameter... Depth below inlet...... Total leaching area..�.,j../.'7_sq. ft.
Other Distribution box Diameter___.._...._.__.
( ) 0
Percolation Test Results Performed by.... ..... Date..................1�.......
Test Pit No. I................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 watenwo
............. . .... . .......... .......................................................................
0 Description of Soil........................ T........................................................
............................... ......
U c......
........... .4...........................
-------------------------------------------------------------16.."Z� -----------*------------------
-,o"/
�ii 77Y
U Nature of Repairs or Alterations—Answer when applicable_________________________ ____•.____._•_______-._._.__-._•_.___.____.__.__._____-...__.._-_-...
.............I.........................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'LIAPIZ4 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 y the boa of hea
.. .. ..... ................................
Application Approved<i;;�--- ..........
6V Date
Application Disapproved for the following reasons:................................................................................................................
.......................1.................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
No......................-- Fus..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. . .
Appliration for Disposal Works Tonstrnrtion rnmit
Application is hereby made for a Permit to Construct ( -+r}`or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address
or Lot No.
.............r.^....__.. '.-...... -• —Owner..... - ----..-- - ............................. r;Adrdress 7... ........._......
a ................................................................................................. .L! . n_..... _ �...........................
Installer Address
Type of Building Size Lot_, ! �±'____2._Sq. feet
Dwelling—No. of Bedrooms...................:.........................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building __ ' :.� _`r"j .No, of persons....___._______________ Showers ( ) — Cafeteria ( )
Other fixture_______________ V
W Design Flow.................. ...................gallons per person per day: Total daily flgw......... .........................gallons.
WSeptic Tank—Liquid capacity! . .!'.gallons Length... ___y�___ 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.-; _'7.sq. ft.
Z Other Distribution box ( ) Dosing tank
r �l nl/r . =�------ Date----.....r........................
, ".
a Percolation Test Results Performed by.....F"...:...........
Test Pit No. 1................minutes per inch Depth of Test Pit. ................ Depth to ground water........ -___ _
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground
1:+4 .................................... _.........--•---.... - ----•-•--------....-------•-•---••---•---....---•--------------•----•--•-••--•---.......----
Description of Soil.........................
...................................... xi--......•--...•---•-••-•---•••-----•••-•••••.........-•-••-•.
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.
K
Signed•• ,
: .fir / / Date
Application Approved BY..................�' �..'..... ...----------------------------- (1� = ��a..
7Date
Application Disapproved for the following reasons---------------•--•----------------------------------•---------------------------...--•-•--•-••---...._--•-_...--
0
.............................•------------........-------•-•------•-----•-•-•--------------•--....------.-•-•••••--•--••••••••-•--•••-----•••---••••••-•-•----••-••-•••-------•-•-------••--•----•......
Date
PermitNo................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifiratp of ont ttnrr
THIS IS T CERTIF t the Individual Sewage Disposal System constructed (. ')-or Repaired ( )
Y..... 'te e' .. -._... - ..... -----------------------------•-----•.
^) Inst lerl
at.. r
Co(JO_
-= ------ :. ... -
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describ in the .
application for Disposal Works Construction Permit N _._?� ,�.�.......... dated-._..____ .._ ........ `
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIONSATISFACTORY.
DATE•-••••••-•-...-•••••••.... ==- 6.............. Inspector -•-•---------------------•---•••-----•-----•-••-•-••-•-•-
THE COMMONWEALTH OF MASSACHUSETTS
rr BOARD OF HEALTH
FEE........................
Disposal Works Tonstrnrtion rrmit ,
Permission is hereby granted = ----------------
'----•--=-=-----•-•--------- - --•-------._.-- {...........
to Construct ( ) or Repair.:( ) an Individual Sewage Disposal System.,
at No
/,.
.. Street
as shown on the application for Disposal Works Construction Permit No.._........3....t Dated___.__ _. -••••.-••.-.•.-
......................................... - ••-• .........................
- / B and of Health
DATE..............:` - i-T .... ......................................
FORM 1255 A. M. SULKIN, INC., BOSTON '
COMMONWEALTH OF MASSACHUSETTS
rt
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Sve
OCT 0 5 2004
TOWN OF L APi,iSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 149 Camelback Road �'��CEI
Marstons Mills MA 02648
Owner's Name: Kevin Condon .
Owner's Address: 5 Timber Lane Drive 77 3"'�_"`"
Katonah NY 10536
Date of Inspection: August 20,2004
Name of Inspector: PATRICK M. O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT
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 I
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a D
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ```10% IIIp�q�i�'
XX_Passes �;.• s'�p'''
Conditionally Passes 'yG%
Needs Further Evaluation by the Local Approving Authority
Fails n LL
Inspector's Si natu4 -�- (� % •'• �Q*�`
P g �- Date: 8/20/2004
FSINSPE �`��
The system inspector shall submit a copy of this inspection report to the Approving Authority 11111111,,`````
pp g ty(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a deign flow of 10,000
s
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.
Notes and Comments: Leaching pit has 2'standing water and has never had more than 3'.
****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.
Title 5 Inspection Form 6/15/2000 page 1
A
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
Titla i rnvnPrti^n Fnrm 411,;i)nnn 2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 149 Camelback Road
Marstois Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
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 privyis within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if 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 I00 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
T41a C Tnc—tin, 17^—4/1 cnnnn 3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
— _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
— _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
Titla C Tncnam;_ An_r,ii si,)nnn 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping informatics was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period?
_ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of
scum?
_X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems`?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information. For example,a plan at the Board of Health.
X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title C lncnortinn 17^rm ail teens 5
f
Page 6 of I 1
OFFICIAL INSPECTIO
N FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
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
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2002—34,000 gal. 2003—27,000 gal.=83 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Tank pumped five years ago.
Source of information: Homeowner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
—Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Compliance date: 12/18/86
Were sewage odors detected when arriving at the site(yes or no): No
Tifla Tnenortinn T+nrm�iT si�nnn 6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'I
SYSTEM INFORMATION(continued)
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron XX_40 PVC_other(explain):
Distance from private water supply well or suction line: 25'
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: V
Material of construction:_X_concrete_metal fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:8.5' long x 5.2'wide- 1000 gal.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 11"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Baffles intact and clear,recommend pumping.
GREASE TRAP: No (locate on site plan)
Depth below grade:—
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Titla S Inenantinn Anr 411 7
f
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
TIGHT or HOLDING TANK: No (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (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.):
Box set level,no solids or hi h stains
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Titla i Tnena tin"T7nr rii;i,)nnn 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
—X— leaching pits,number: One 6x6 pit
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.): _
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY: No (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.):
Tiflc C Tncnarfinn T nrm(./1 C/�!1(1!1 9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
Camelback Road
Uj
Z�
3�
3l
1000 gal tank
D-box
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Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 149 Camelback Road
Marstons Mills MA 02648
Owner: Kevin Condon
Date of Inspection: August 20,2004
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 25 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el.50 and topo map shows property above el. 100.
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