HomeMy WebLinkAbout0170 FLUME AVENUE - Health 17-0 FiuivlE W- 11b,'
MARSTONS MILLS
A = 061 013 001
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Commonwealth of Massachusetts o(PI ' b 13 " 001
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
J� 170 Flume Avenue, M'arstons Mills, MA
V�
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is
required for every Shrewsbury MA 01545 11/13/2019
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information Sj �� p
filling out forms
on the computer,
use only the tab Joseph M Martina
key to move your Name of Inspector
cursor-do not Accu Sepcheck
use the return Company Name
key.
de ✓e
Company
o
� Companyparry Address
South Dennis MA 02660
City/Town State Zip Code
508-385-5891 SI 147
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 Funher Evaluation by the Local Approving Authority
4. ❑ F
12/3/2019
In ector'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
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is required for every Shrewsbury MA 01545 11/13/2019
page. City/Town 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:
GARBAGE GRINDER HAS BEEN REMOVED. SEPTIC TANK HAS BEEN PUMPED . SEE
ATTACHED DOCUMENTATION.
2) System Conditionally Passes:
❑ One or more system components as described in the "Condi ' nal Pass"section need to be
replaced or repaired. The system, upon completion of the placement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* o the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfi ation or tank failure is imminent. System will pass
inspection if the existing tank is replaced wit a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspec .on if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tan Is less than 20 years old is available.
ElY ❑ N ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is
required for every ShrewsburyMA 01545 11/13/2019
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, settiA 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 ed ❑ Y ❑ N ❑ ND (Explain below):
❑ The system req . ed pumping more than 4 times a year due /NDplain
pipe(s). The
system will pa inspection if(with approval of the Board of H
❑ bro n pipe(s) are replaced ❑ Y ❑ low):
❑ bstruction is removed ❑ Y ❑ low):
3) Further Evaluation is Required/functioning
d of ealth:
❑ Conditions exist which requil tion by the Board of Health in order to determine if
the system is failing to protesafety or the environment.
a. System will pass unlessalth determines in accordance with 310 CMR
15.303(1)(b)that the systetioning in a manner which will protect public health,
safety and the environmen
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
r
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
1- A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is required for every Shrewsbury MA 01545 11/13/2019
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 wetla d or a salt marsh
b. System will fail unless the Board of Health (and Public Wat upplier, if any)
determines that the system is functioning in a manner that tects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption sys m (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surf a water supply.
❑ The system has a septic tank and SAS and the AS is within a Zone 1 of a public water j
supply.
❑ The system has a septic tank and SAS an he SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SA 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 w er analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absen nd th presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, pro ded at n ther 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
M Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is required for every ry
Shrewsbu MA 01545 11/13/2019
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 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 fac" ' 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 f ing, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 fe f surface drinking water supply
❑ ❑ the system is wit ' 200 feet of a tributary to a surface drinking water supply
❑ ❑ the syste ' located in a nitrogen sensitive area (Interim Wellhead Protection
Area— PA) 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is ShrewsburyMA 01545 11/13/2019
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have 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?
lrxd
® ❑ Were all system components, a ing 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
Title 5 Official Inspection Form
�- i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is ShrewsburyMA 01545 11/13/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
1500 GALLON SEPTIC TANK, DISTRIBUTION.BOX, AND INFILTRATORS IN A 35'X1 2'X2' STONE
VOLUME.
Number of current residents: 1
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 ears usage d 242
9 ( Y 9 (gP ))�
Detail:
2017: 65,000 G ; 2018: 112,000 G . HAS LAWN IRRIGATION
Sump pump? ❑ Yes ® No
Last date of occupancy: 11/13/2019Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is ShrewsburyMA 01545 11/13/2019
required for every
page. City/Town State Zip Code Date of Inspectign
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): G ons per day(gpd)
Basis of design flow(seats/persons/sq.ft., et
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 t Title 5 system? ❑ Yes ❑ No
Water meter readings, if availa e:
Last date of occupancy/us Date
Other(describe belo
3. Pumping Records:
Source of information: PUMPED IN 2003 PER BWWTP,ALSO PUMPED
AFTER INSPECTION 1500 G, SEE ATTACHED
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
r� .. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is
required for every ShrewsburyMA 01545 11/13/2019
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:
APP 21 YEARS. PLAN DATED 1998, PER BARNSTABLE HEALTH DEPT.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: —2, BEHIND WALL
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.):
SEWER PIPE NOT VISIBLE. NO EVIDENCE OF LEAKAGE. NO ODORS.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
I '
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is ShrewsburyMA 01545 11/13/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
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: APP 10 X6X5 1500 G
Sludge depth: 12 INCHES
Distance from top of sludge to bottom of outlet tee or baffle 17 INCHES
Scum thickness 3 INCHES
Distance from top of scum to top of outlet tee or baffle 6 INCHES
Distance from bottom of scum to bottom of outlet tee or baffle 19 INCHES
How were dimensions determined? CORETAKER
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
INHAS PVC INLET TEE. HAS OUTLET TEE BOTH PVC AND IN GOOD CONDITION. LIQUID
LEVEL IS 48"AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE. INSPECTOR BUILT UP INLET
COVER W RISER TO WITHIN 6"OF GRADE.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
°. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is
required for every ShrewsburyMA 01545 11/13/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
'
Depth below grade: N/Afeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylen ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or e
Distance from bottom of scum to bottom of tlet to or baffle
Date of last pumping: Date
Comments (on pumping recom ndations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to out invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locat on site plan):
Depth below grade: N/
Material of construction:
❑ concrete ❑ metal ❑ fiberglas ❑ 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
M Title 5 Official Inspection Form
1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is
required for every ShrewsburyMA 01545 11/13/2019
page. City/Town State Zip Code Date of Inspecti n
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes No
Alarm level: Alarm' working order: ElYes ❑ No
Date of last pumping: Date,"
Comments (condition of alarm and fl at s it s, ):
"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 AT INVERT
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
DISTRIBUTION BOX IS IN GOOD CONDITION. NO EVIDENCE OF LEAKAGE. PIPE EXITING
DBOX IS CLEAN ABOVE INVERT.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
r -
C Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is required for every Shrewsbury MA 01545 11/13/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: es ❑ No*
Alarms in working order: [IYes ElNo*
Comments (note condition of pump chamber, onditioXofps nd appurtenances, etc.):
* If pumps or alarms are not i orking order, system is a conditional pass.
11. Soil Absorption Syste AS) (locate on site plan, excavation not required):
If SAS not located, a lain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4INFILTRATORS
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: j
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
I.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is required for every Shrewsbury MA 01545 11/13/2019
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.):
HAND BORING ADJACENT TO INFILTRATORS. BOTH SOIL AND STONE ARE CLEAN WITH NO
EVIDENCE OF HYDRAULIC FAILURE.
{
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site pl ):
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 (nose condition of soil, sign f 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
1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>t�
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is
required for every ShrewsburyMA 01545 11/13/2019
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 fire, 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
Commonwealth of Massachusetts
6z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
IRV"" 170 Flume Avenue, Marstons Mills, MA
`J Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is Shrewsbury MA 01545 11/13/2019
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
A PAL- -r
W
0 0
I 2 .
A! =(-1I.Sr 13I =35'
Az-.: tf:K f Bz- 2,?"
�Y= 60' B4 --YZ '
t5insp.doc•rev.7/26Q018 Title 5'Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
1- b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is required for every Shrewsbury MA 01545 11/13/2019
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: >8' below SASfeet
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: NO BBOH SIGNOFF
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:
DESIGN ELEVATION, CCC GROUNDWATER CONTOUR, FRIMPTER
You must describe how you established the high ground water elevation:
DESIGN TEST HOLE ON 8/24/1998: NO GROUNDWATER AT 11' . GRADE TO SAS BOTTOM IS
5.0'. ALSO, PER DESIGN : ELEVATION IS 52 'ASL W A GROUNDWATER CONTOUR OF 36'
ASL AND A MAX RISE OF 3'for SDW253 zone C'. SEPARATION MATH: 52-(36+5+3)=8'.
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
M , Title 5 Official Inspection Form
1- 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Avenue, Marstons Mills, MA
Property Address
Leona Joseph 10 Guinevere Circle
Owner Owner's Name
information is Shrewsbury MA 01545 11/13/2019
required for every ry
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: Tigrt/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
A-DADS Plumbing & Heating, LLC Invoice
PO Box 702 Date "" Invoice`No.
W Barnstable, MA 02668 11/21/19 13361
Phone 508-362-9436
Fax 508-362-4243
Bill To:
Meagher Construction
772 Main St
Osterville, MA 02655
Project..: Terms
170 Flume Ave Due on receipt
Description, Qty%Hrs Rate Amount
Removed garbage disposal and repiped drain, basket, strainer, and
dishwasher tailpiece
"Left disposal on garage shelf
Labor- Minimum of 1 hour 1.5 120.00 180.00
Materials used to complete job 108.00 108.00
i
Total a $288 00
Balance Due $288.00
a
Robert B Our Inc.
PO BOX 1539
Harwich,
Massachusetts 02645-6539,
United States
P.:508-432-0530
E.:scleary@robertbour.com
wW W.robertbour.col`
,Invoice Submitted To: 0
ffiW
Built on trust
Steven Joseph
Steven Joseph 170 Flume Avenue
Marstons Mills, mom ,
:Massachusetts 02648,
United States invoice# 8327015A
P.:508-667-3194 Invoice Date 20-Nov-2019
Terms Credit Card
8327015 Steven Joseph 170 Flume Avenue,Massachusetts,Marstons Mills,
02648,United States
Barnstable 1500 Gallon Septic Tank 1.00 330.00 0.00 330.00
Total $330.00
(+)Tax $0.00
Grand Total $330.00
Amount Paid ; $330.00
Amount Due $0.00
Job Notes: Septic
Pumped 1500 gallon septic tank.Paid with credit card
Invoice Notes:
PAYMENT STUB Client Steven Joseph
Robert B our Inc. Client Phone 508-667-3194
PO BOX 1539 Invoice# 8327015A
Harwich, Invoice Date 20-Nov-2019
Massachusetts 02645-6539, {mount Paid 330.00
United States
P.:508-432-0530 Amount Due $0.00
E..-scleary@robertbour.com Amount Enclosed
a
TOWN OF BARNSTABLE
LOCATION ( U tom'- b�►" .E a it Cr
r� ILLAGE,MI Im tit1S ASSESSOR'S MAP&PARCEL
�'S NAME&PHONE NO. r'LlG O(>/oyikq I/
SEPTIC TANK CAPACITY I Sao
LEACHING FACILITY: e q; n� (ThY0 r3
(typ ) —�n�-��'f (size)
NO.OF BEDROOMS
OWNER 1^S
PERMIT DATE: C ATE;._V"SiP -] 1-29 40
Separation Distance.Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY PW
Flume Ave, .,
48
25 53
. 28 \ k \ \ • \ \ \ \ \ \ _ ..
V
f f f f ! f f I f i f f f f f f f f / f ! f I f f f f f f f f /•/ f !'% J f
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
..'' 170 Flume Ave. —
Property Address
Meyers —
Owner Owner's Name
information is Ma tons Mills MA 02648 July 28, 2010
required for State Zip Code Date of Inspection
every page. Cityrrown
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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell —
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co. —
Company Name
189 Cammett Road —
Company Address
Marstons Mills MA 02648 _
Citylrown State Zip Code
508.428.1779 SI 12855
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000).The system: o 0
o
® Passes ❑ Conditionally Passes ❑ Fails cm Z
—+ o
❑ Needs Further Evaluation by the Local Approving Authority -n
s cgs
� z
July 28, 2010 Job# 10-18P co
In ector's Signature Date fV D
W
The system inspector shall submit a copy of this inspection report to the Approving A oritpBoard
of Health or DEP)within 30 days of completing this inspection. If the system is a share 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
t5ins-09108
V v
la .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 170 Flume Ave. —
Property Address
Meyers —
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 28, 2010 —
every page. Cityrrown 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 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:
Tank is not in need of pumping at this time. Leaching system shows no signs of surcharge or
saturation. —
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 170 Flume Ave. —
Property Address
Meyers - —
Owner Owner's Name
information is required for ate Marstons Mills MA 02648 July 28, 2010
—
every page. Cityrrown St Zip Code Date of Inspection —
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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•09/08 Title 5 Official Inspection Form: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
.' 170 Flume Ave. —
Property Address
Meyers
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 28, 2010
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 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 sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than_day flow
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 o1 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Ave. —
Property Address
Meyers —
Owner Owner's Name
information is Marstons Mills MA 02648 July 28, 2010
required for St —
every page. Cityrrown ate Zip Code Date of Inspection —
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any 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. [Ms
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 considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09108 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
170 Flume Ave. _
Property Address
Meyers
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 28, 2010
-
every page. Cityfrown 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 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)]
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•09/08 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
170 Flume Ave. _
Property Address
Meyers _
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 28, 2010
every page. City/town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Unknown—
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d N/A irrigation
g ( y g (gp ))' system. _
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
Occupied
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•09/08 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Flume Ave. _
Property Address
Meyers —
Owner Owner's Name
information is Marstons Mills MA 02648 July 28, 2010
required for —
every page. City/town State Zip Code Date of Inspection —
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Flume Ave.
Property Address
Meyers
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 28, 2010 _required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'feet —
Material of construction:
❑cast iron ®40 PVC ❑ other(explain): —
Distance from private water supply well or suction line: feet —
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2'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:
10.5' long x 5.8'wide- 1500 gal. —
Sludge depth: 3" —
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Ave. —
Property Address
Meyers —
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 28, 2010
-
every page. Cityrrown 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"
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Measured —
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees were found intact and clear, liquid level was at bottom of outlet invert. Tank is not in need of
pumping at this time. —
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Flume Ave. _
Property Address
Meyers _
Owner Owner's Name
information is Y Marstons Mills MA 02648 Jul 28 2010
required for � _
every page. Cityfrown 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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: —
Material of construction:
❑.concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: —
Capacity: —
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date —
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
l5ins•09/08 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
170 Flume Ave. _
Property Address
Meyers _
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 28 2010
required for Y
every page. City1rown 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 distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Observed a trace of solids carryover, no high stains. Liquid level was found at bottom of outlet pipe.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Ave. _
Property Address
Meyers _
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 28, 2010
-
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number: —
® leaching chambers number: Infiltrators —
❑ 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.):
Area of SAS was probed with no signs of saturation found. —
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. ' 170 Flume Ave. _
Property Address
Meyers
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 28, 2010
every page. City/Town 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•09108 Title 5 Official Inspection Form: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
170 Flume Ave.
Property Address
Meyers
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 28, 2010
required for Y
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
Flume A ve
48
25 53
28 \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \
\ \ ti \ \ ♦ \ \ \ \ \ \ ♦ \ \ \ \ \ \ \ \ \ \ \ \ ♦ ♦ ♦ \ \ \ ♦ \ \ \ \ \ \ \
r r / / J J J J r / / J J J / / / / J / / f / / / r r r /
/ f / / / r / / /
/ r / f / / f / f J r /
/ / f / J f / / r / r / / / /. . . . . . .. . . .
f / / f / r f / / f
\/\J\f♦/\f♦/♦!\J\!\/\
♦ \ ♦ ♦ \ \ ♦ \ \ \ ♦
r J ! / / f / J J /
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Ave.
Property Address
Meyers
Owner Owner's Name
information is Marstons Mills MA 02648 July 28, 2010
required for —
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
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. 40 and topo map shows property at el. 50.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Flume Ave. —
Property Address
Meyers —
Owner owner's Name
information is Marstons Mills MA 02648 July 28, 2010 —
required for
State Zip Code Date of Inspection
every page. Cityrrown
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
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal S g Po System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION 1 0 f V VNt lave- E#45e
-V ry,LAGE ASSESSOR'S MAP&PARCEL U( 013-Od1
S NAME&PHONE NO' r-t!c.j- O�oA rKJ I Yak- m
SEPTIC TANK CAPACITY ,BOO
LEACHING FACILITY:(type) din (�r-4,ior-, (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: G&� -DATE: lc-)O ®(�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
WAO
f
Fume Ave
ater
Service16
{
Riser installed on
tank outlet cover as
part of inspection
48
f 25 8 53
i �
y
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
J
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 170 Flume Avenue
Marstons Mills MA 02648 `
Owner's Name: Neal Coughlin
Owner's Address: Same
Date of Inspection: December 20,2006 Job#06-316 �
1'
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648 =, e
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT r�
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 basedlon my
urrr,training and experience in the proper function and maintenance of on site sewage disposal systems.I am a IZRP`• iq
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X_ Passes 'O�• • P r,IC .yin;
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority = 'CO�;
Fair---�
RMF1*o;p�'
Inspector's Signature: Date: 12/20/06 �'',,i�Fs INSPE�'\\��`��
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.
Notes and Comments: Leaching system has no evidence of saturation and tank is not in need of pumping.
""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.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
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:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
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
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
surface water supply or tributary to a surface water supply.
The system has aseptic 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 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:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
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_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.
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_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 recent) or as art ofthis. �g y y p 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)]
r
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 170 Flume Ave, Marstons Mills
Owner: Neal.Coughlin
Date of Inspection: December 20,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 440
Number of current residents: unknown
'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):
Seasonal use:(yes or no):No
Water meter readings,if available(last 2 years usage(gpd)): Two years total w/irrigation: 411,000 gal.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
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 in July 2003,2005.
Source of information: Owner
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: 10/30/00
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
BUILDING SEWER:XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:
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: 10.5'long x 5.8'wide—1500 gal.
Sludge depth: 2"
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: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
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.):
Tees are intact and clear,liquid level at bottom of outlet invert Tank has been pumped every two
years,tank due for pumping in July 2007
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.):
Page 8 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
i
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
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.):
No solids or hieh stains,liquid level at bottom of outlet pipe.
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.):
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_leaching pits,number:
_X_leaching chambers,number: 5 Infiltrators.
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.): Leaching system has no signs of surcharge or saturation area of SAS was probed and stone and soil
was found dry.
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.):
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: 170 Flume Ave, Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
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.
Flume A ve
ater
fiR. Y Service
,.,
t
�� tdd�IS trr
hh K 4
1 fiy;
A;
Riser installed on
tank outlet cover as
part of inspection
48
25
8 53
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 170 Flume Ave,Marstons Mills
Owner: Neal Coughlin
Date of Inspection: December 20,2006
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 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.40 and topo map shows property above el.60.
qy� �LYy
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS '
Wintered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
01pprication for 3f.4pooar *pftem Con5truction 3dermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.170 F 1 u ill e Ave Owner's Name,Address and Tel.No.
Assessor's Map/Pazce
Marstons Mills Bayside Building Co. Inc.
Mai2 61 Pcl
Installer's Name,Address,and Tel.No. 013, 0Q 1 Designer's Name,Address and Tel.No.
� `1, � T1e��U Baxter & Nye Inc.
812 Main Street Osterville 428-91 1
Type of Building:
Dwelling No.of Bedrooms �� 7 Lot Sizecg�63-7 sq.ft. Garbage Grinder
Other Type of Building ""°� WA*.k- No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 9TO gallons per day. Calculated daily flow wo gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank S Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by this B o e th.
Signed w�``"�"" Date
Application Approved by Date :,,Z.-'I
Application Disapproved for t e following reasons
Permit No. - Date Issued
I _
Fee /442 —
F �• aT
THE COMMONWEALTH OF MASSACHUSETTS, ntered in computer: Yes
PUBLIC HEALTHDIVISION - TOWN OFBARNSTABLE MASSACHUSETTS V
f t` f, Mt-4poot *rmem Construction permit
Application for a Permo C nsttuct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components
Location Addressor Lot No.t70 Flume Ave Owner's Name,Address and Tel.No.
Assessor's Map/Pazce
Marstons Mills Bayside Building Co. Inc.
map 61 Pcl P.O. Box 95 Centerville 771-1040
Installer's Name,Address,and Tel.No. 013, 001 Desi ner s Name,Address and Tel.No.
9j�1� Q4/7y 812 Main Street Osterville 428-91 1
Type of Building: u
Dwelling No.of Bedrooms 7 Lot Siz�eo2.� 37 . sq.ft. Garbage Grinder WL))
¢ No.of-Person's `'" Showers
Other "Isype�ofYBuilding ( Cafeteria( )
Other Fixtures A -'
Design Flow } Y, h 1 Ngallons per day. Calculated daily flow yyU gallons.
Pl
an Date ' 1 Numb Fof sheets Revision Date
Title fi 1
Size of Septic Tank S Type of S.A.S.
Description of Soil
IF
Nature of Repairs or Alterations(Answer when applicable)
+ F
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by this B 0 a a lth.
Sig ned 5�6""-I— Date
Application Approved by Date
Application Disapproved for t e following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance /
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(V )Repaired( )Upgraded( )
Abandoned( )by KA-1 CATE?_1A/0
at I'70 FL U M r flU.r-- /V. ✓h 11-L•S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer s r
The issuance of this pe t� h 11 n-/t`b>eijconstrued as a guarantee that thus s em/will feuunction as desig eda/ , V �`�
Date � J �/0 Inspector J �V,//1`!��� 1�e� � l�l/ ��� a 1�-i'
--------------- - -------------
No. / Fee !(!:5n
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
i�p0iff *p.5tem Construction permit
100,
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at /?G FaU/7F LIVE /H. M ILLS r�
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions:"s
Provided:,Construction must be completed
letted within,three,yea�s of the date of th' t.
Date: .�-i-� � Approve
TOWN OF BARNSTABLE �
LOC 4TION �� / ` � SEWAGE #
Qq
VILLAGE /YI� s ht���s ASSESSOR'S MAP & LOT
INSTALLERS NAME&PHONE NO./-}}�� �fl � �1�`7
SEPTIC TANK CAPACITY _ 5 00
LEACHING FACILITY: (type (size) S
NO.OF BEDROOMS �
BUILDER OR OWNER,
PERMITDATE: COMPLIANCE DATE: Y� D 0
Separation Distance Between the: �.
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist..
on site ormithin 200 feet of leaching facility). :} Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) `` Feet
Furnished by
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TOWN OF BA.RNSTABLE
LOCATION `/7�'— fIG�— SEWAGE #
VII.,LAG ��/ 4 ASSESSOR'S MAP & LOT 3
E� �11J111
I INSTALLER'S NAME&PHONE NO. �14) 32F9�
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I SEPTIC TANK CAPACITY 500
LEACHING FACILITY: (type (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE: ® ��
Separation Distance Between the:
iMaximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
. Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
qj
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Department of Ilealth,Safety,and Environmental Services _L
Public Health Division uaIle��_
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Date Scheduled=-- #1 7
Soil Suitability �lssessuie11t for Seivage.Disl�o s
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Performed By: tc� "�
x _ Witnessed By: � �
LOCA` 41ON & GENE1tAL LNfiUlI—MATt0N
oWner'sNow Indian La7Dev. r.
i.ocation Address
Lotg Flume Ave AddressP.O. Box 95�iIMI Centerville, 02 33
Engineer's Name
Assessor's Map/Parcel: Map 61 Pcl 10 (Part) Baxter & Nye Inc.
NI., CONS'iRUCTION
x REPAIR Telephone N .428-9131
� p �� Surface Stones ��1��`9J L_ Slopes(e ,)
Land Use ��
water Well
ter Body-'
Distances from: Open Wit
�2ov R Possible Wet Arco �o®R Drinking —
` 3cc R. Other R
Drainage Way__—0 n Property Line
q yt
t t
S1{L')('CII:(Street name,Dimensions of 101,exact locations of test holes&perc tests,locate wetlands In proximity to holes)
p t� 199.92in ' NO
i8 0 0'
o — xz�lJ
�
Lo 8 `�
CNLL
t
�r Z
N81'44'27"W
I
1 g
L)cpllt to Bedrock
Parent material(geologic)� •y--L'� r
Weeping from Pit face
Dcplh to Groundwater: Slnrlding Wntcr in i tole:
Estiutnlcd Seasonal high Groundwater --_---
1 t■ ) N 1 fp H.yt .. . .) S p* 1, Y{] ev T 1 A T
1� ��U�``J 11�JA1��N!•CJ B.Y1�D1\ WA'II,/�J��IA'['h.,�I.JE'.: :.
Method Used: __ __-...-- ----- ln. Depth to soil mollies:
in.
Dcpih Observed stnnding ur ob.s.hole: - -- + Ill. (itr0ndwalcr
Depth to Wccping fr0rn shlc ofobs.hole: _.—._-._..-._-._ -- A,Ij.L,�lor Ad}.(.iroundtvnter l..ev,ci---
Inde.e Well N_. '!trading Date:
h)dcx%Vchl Icvcl
t'I�JItCOLNTION rf' ,81 tia.te_78 1-4 11me_I,
6
observation ime at 9"
hltc at G" -_
e
Depill of rctC 11--- t iris
Slnr�P�•�nnk'1'In�a r!c
�N L�', `0_3"i"(}v U�'1�' "IIrn�.(9"-G'•) —
End Pre-conk 1+ -- /j
hale Min./Inch
AJJitionnl'1'csling Ncedcd(YM)•`---_
�,/, Site Failed:
Site Suitability Assessment: Site t'asscJ _ ,-------
Original: Public Health Division
Observatial hole Vita To Be(:ompleted on hack- )
DEE11 OBSERVATION HOLE LOGSoil tlnle# l
Depth from Soil I lorizon Soil Texture Soil Color Molding (Structure'ler Stones,Boulderes.
Surface(in.) (USDA) (Munsell)
Consisicricy e
O w
DEEP OBSERVATION HOLE LOG- ': Hole# -
Depth from Soil I lorizon Soil Texture Soil Color Soil Other
(USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Surface(in.)
DEEP GIBE RVATION HOLE LOG ` 1lole# '`
Depth from Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
e
DEEP OBSERVATION HOLE LOG thle#
Dcplh from Soil Ilorizon soil'rexture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulderes.
e
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Depth of aturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
—41�1—
If not,what is the depth of naturally occurring pervious material?
Certification V
I certify that on Jqq (date) I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training, expertise and experience described in 310 CMR 15.017.
Date,
l_
4 TOTAL UNITS 1 STARTER,1 END. Qc 2 INTERMEDIATES. f •`
1. THIS PARCEL IS NOT LOCATED IN THE FLOOD PLAIN. 330S 4 TYP. 3301330E i b t LD /y
IT / �.
2. THERE ARE NO WETLANDS LOCATED WITHIN 100' OF THIS LOCUS. 4._,_7.6 6.25 .:2 4.4 / pR.A,NA
3. REMOVE UNSUITABLE SOILS BENEATH PROPOSED SYSTEM, BACKFILL 1-1s" WASHED STONE N81�44,27„ )1S ENT
WITH CLEAN GRANULAR MATERIAL FILL TO BE GRADED AS FOLLOWS. NOT �-. ;n 1 W
MORE THAN 15% RETAINED ON No. 4 SIEVE, NOT MORE THAN 909% RETAINED 19
ON No. 50 SIEVE, OF FRACTION PASSING No. 4, 10% OR LESS TO PASS No. apl :^ 1 92' p 1 87.00' 1'
100 SIEVE AND 5% OR LESS TO PASS No. 200 SIEVE, SOIL TO BE APPROVED
35 00'
BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING ON SITE. '--
4. LOCATION OF UTILITIES NOT SHOWN ON THIS PLAN, AT LEAST 72 HOURS PLAN OF LEACH C$Al� J' G` 87•00'
PRIOR TO ANY EXCAVATION FOR THIS PROJECT CONTRACTOR SHALL MAKE No SCALE cc 24 /
THE REQUIRED NOTIFICATION TO DIG SAFE (1-888-344-7233) AND APPROPRIATE { { 1 �`� �� GAIN, PROPOSE
WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. V OR(vEwAY
[/
N DATA FINISHED GRADE o' t f i �X =1 43Y ,j y
36"MAX.- 12"MIN. COMPACTED FILL
1
SINGLE FAMILY- 4 BEDROOMS 2.I a. PEASTONE i W - D 2 WATER
NO GARBAGE GRINDER Z t I a 3/4- TO 1 1/2 " e Tj//�T SERNCE
DAILY FLOW = 110 X 4 = 440 G.P.D. DOUBLE LOT s W iLLJ3
SEPTIC TANK 440 X 200% = 880 ` 'e WASHED STONE 1 2
USE 1500 GAL. SEPTIC TANK5,637 sq.ft. s ,
i \ � � oo %
C[1I.?RC LZAC� CRAMRBR DZMGN SECTION � � N8 r���>,W ^ '� 0
Td=Amn MDR OR RQUIVAI�ENT NO SCALE 276.56'
ALL PIPES TO BE SCHEDULE 40 PVC PERFORATED
WITH CAPPED ENDS
USE 1 - 4" DISTRIBUTION LINE IN 4 RECHARGER UNITS I CERTIFY THAT THE PROPOSED FOUNDATION
IN A 12'X 35' WASHED STONE TRENCH AS SHOWN COMPLIES WITH THE TOWN OF BARNSTABLE SIDELINE
LEACHING AREA REQUIRED AND SETBACK REQUIREMENTS AND IS NOT LOCATED
440 G.P.D./.74 = 595 S.F.
WITHIN THE FL❑ D LAI '
2(35 + 12) X 2 = 188 S.F. SIDEWALL AREA DATE: 91.9 R.L.S.
(12 X 35) = 420 S.F. BOTTOM AREA THIS PLAN IS NOT BASED ON AN INSTRUMENT SURVEY AND
608 S.F. TOTAL PROVIDED THE OFFSETS SHOULD NOT BE USED TO DETERMINE LOT LINES.
PERCOLATION RATE 1"IN 2'OR LESS 8/14/98 SCALE; 1"= 40'
CERTIFIED OF
PLAN
SOIL CLASS 1 TEST HOLE. ��a
BAXTER & NYE INC. ��P���
p� STEPHEN AMN
#P-9210 LOT 8 FLUME AVENUE
COVERS LOCATED TO WITHIN � AL �
F.F. ELEV. = 55.0 6" OF F.G. I PIT #1 Pir # 0 MARSTONS MILLS
ELEV. = 54.0' 2ELEV. 52.0 0.30216 �' pe
O HUMUS 0 HUMUS i .
F.c.= 53't F.c.-53't -2" -2 exfil
" 9 'FF �O �Q AUG.17,1998
t.c�53' A LOAMY SAND A LOAMY SAND GINTER �,
� - LEVEL - - 'x -6" -6" FS'
- - S
INV. = a B LOAMY SAN B LOAMY SAND Id
i3ix5 GAL 4• 2 D AL
T LEACHING CHAMBERS -3 -3'
51.o wso s . �"C TANK ,"V - '�� DINT.' c"EDutE�P.I.C. '� HERRING RUN AT INDIAN LAKES
50-6 INV. -50.4 BOX -4' PERK TEST -4' PERK TEST
..»INV. -50.2 INV. '
50.0 SUBDIVISION #762
=-- '-• =`- -- s" STONE BASE----------:
>
o>` ASSESSORS MAP 61 PARCEL
MIN. �.Cl COARSE ?.? Cl COARSE.
BOTTOM ELEV. EL =48.0 SAND SAND Rp BAXTER 8C NYE INC.
10YR.6/4 10YR.6/4 A = LAND SUR$, � m VEYORS, CIVIL ENGINEERS
-s' :-6' Vo 24049
OSTERVILLE,MASS.
PROF= F C2 COARSE SAND C2 COARSE SAN �D T Tf'f��
NO SCALE N-11'
I NO WATER -11'I NO WATER a A UCA `•
ELEV. =43.0' ELEV. = 41.0'
ti BAYSIDE BUILDING CO. INC.
#97012TYP
I