HomeMy WebLinkAbout0031 LIBERTY LANE - Health 31` Liberty Lane `
Marstons Mills P
A = 124 004015
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Liberty Lane, Marstons Mills V
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is 113 1/2 15 tr, Street, Pacific Grove CA 93950 3/21/16 `
required for every
page. City/Town State Zip Code Date of Inspeton
4A
C?-
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. general Information (�
filling out forms v/,o
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Samuel Speakman _
use the return Name of Inspector
key.
Speakman Excavating LLC
Company Name
15 Speak Way
Company Address
Harwich MA 02645
CitylTown State Zip Code
508-432-5565 S113817 _
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 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/24/16
Inspector's Si ature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
kq� rs
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every to 113 1/2 15 Street, Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
B. Certification (coat.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 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:
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 bellow):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's(dame
information is required for every 113 1/2 1510 Street, Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every th 113 1/2 15 Street, Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ❑ Backup of 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin'-Read Rev. Trust
Owner Owner's Name
information is required for every to 113 1/2 15 Street, Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of 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. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is 113 1/2 15tl, Street, Pacific Grove CA 93950 3/21/16
required for every
page. Cityrrown 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?
❑ Z. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 1510 Street Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2015 - 165,000 gal
2014 -93,000 gal
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
qw 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 15tr, Street, Pacific Grove CA 93950 3/21/16
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
'Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° .N 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 151h Street, Pacific Grove CA 93950 3/21/16
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1991
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 104
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
in good condition
Septic Tank(locate on site plan):
Depth below grade: 1 —
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1,000
Sludge depth: 8"
t5ins•3/13 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
31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 1510 Street, Pacific Grove CA 93950 3/21/16
page. City/Town 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
26"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
2"
Distance from bottom of scum to bottom of outlet tee or baffle
14" �
How were dimensions determined? tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tank in good condition, maintanance pumping is recommended 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 15to Street, Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 15to Street, Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
Do 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.):
18" from grade, in fair condition
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms
a ms in working order: El Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 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
31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 15to Street Pacific Grove CA 93950 3/21/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
one six foot pit with stone, cover 18"from grade, high water stain 40"from bottom
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 151h Street, Pacific Grove CA 93950 3/21/16
page. Cityfrown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.0 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 15th Street, Pacific Grove CA 93950 3/21/16
page. City/Town 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
44
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33 3a
I
I TI
I f
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 15tl, Street, Pacific Grove CA 93950 3/21/16
page. City/Town 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: 25feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
previous inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 31 Liberty Lane, Marstons Mills
Property Address
Kathleen Rankin - Read Rev. Trust
Owner Owner's Name
information is required for every 113 1/2 15to Street, Pacific Grove CA 93950 3/21116
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r �
K
ECOJECH hvlH = 2005
Environmental TOWN OF BARNSTABLE
HEALTH DEPT,
www.eco-tech.us
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 31 Liberty Lane
Marston Mills -,P
Owner's Name: Scott Lowe ARCEI.
Owner's Address: P.O. Box 875
Marstons Mills,MA 02648 r�
Date of Inspection: March 14,2005 `"� ""` -- •
Name of Inspector: (Please Print) David D. Coughanowr,R.S.
Company Name: Eco-Tech Environmental
Mailing Address: 43 Triangle Circle
Sandwich,MA 02563
Telephone Number: (508)364-0894
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
training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature ,�VK-®. 4J4----- kS Date: Agrcli (41 1045
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
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****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
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14, 2005
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 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,or 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 breakout or high static water level in the distribution box is due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. The 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 four 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
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14,2005
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 and 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 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 by 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
3
-Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14,2005
D) System Failure Criteria applicable to all systems:
You must indicate either"yes" or"no" to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.
The basis for this determination is identified below. The Board of Health should be contacted to determine what
will be necessary to correct the failure.
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 1/2 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 groundwater 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 by 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14 2005
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
Y _ Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y _ Were all system components,exelud the SAS. located on site?
Y _ Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal stems lease o to:
P P P systems P g
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y Existing information. For example,Plan at the Board of Health.
Y 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)]
5
i-
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14, 2005
FLOW CONDITIONS
RESIDENTIAL
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 gpd
Number of current residents 1
Does the residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection requiredl
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings, if available(last two year's usage(gpd): 201 gpd
Sump Pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/IN D U S TRIAL:
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
Source of information: System not pumped in recent past(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/Alternate 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:
i
Age: 13+years Certificate of Compliance issued 12/27/91 (BOH permit#91-450)
Were sewage odors detected when arriving at the site: (yes or no) no
6
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14,2005
BUILDING SEWER_(Locate on site plan)
Depth below grade: 2 ft
Material of construction:—cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting, evidence of leakage, etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling
SEPTIC TANK:Yes (locate on site plan)
Depth below grade: 1 foot
Material of construction: X concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 4 in
Distance from top of sludge to bottom of outlet tee or baffle: 30 in
Scum thickness: 1 in
Distance from top of scum to top of outlet tee or baffle: 9 in
Distance from bottom of scum to bottom of outlet tee or baffle: 14 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every 2 years Liquid level at
outlet invert.Tank and tees appear structurally sound and functioning as intended No evidence of leakage in or out
GREASE TRAP: none (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.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane
Marston Mills
Owner: Scott Lowe
Date of Inspection: March 14,2005
TIGHT OR HOLDING TANK: none (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 inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
D-box appears structurally sound with no evidence of leakage in or out Effluent level at outlet invert
Few solids in sump.
PUMP CHAMBER: none (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.):
8
r Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14,2005
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
If SAS not located, explain why:
Type:
X leaching pits,number 1
_leaching chambers,number
_leaching galleries, number
_leaching trenches, number,length
_leaching fields,number,dimensions
_overflow cesspool,number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
Soils above leaching pit appeared unsaturated No evidence of surface ponding breakout, lush vegetation or
other evidence of hydraulic failure was observed. Leach pit was uncovered and found to be dry.
CESSPOOLS: none (cesspool must be pumped at time 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: none (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14,2005
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'(Locate where public water supply enters the building)
LEACH
O PIT LOCATIONS
S
A B
2 1 42.5 f t 46 f t
❑ D-BOX 2 33 f t 39 f t
3 22 ft 30 ft
SEPTIC
TANK on
A EXISTING e
DWELLING
# 31
j
Z
J
W
W
G
3
I
LIBERTY LANE NOT TO SCALE
10
i
l
` Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane
Marstons Mills
Owner: Scott Lowe
Date of Inspection: March 14,2005
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to ground water: 25 feet
Please indicate(check)all methods used to determine 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 local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Town of Barnstable GIS Department records indicate that property is 25 feet above groundwater elevation
III
ll
(Z)L
COM=Meatth of Massachusetts
Executive Office of Environmental Affairs John Septic
D.E.P. Title V S Septic Inspectorapartment of P.O. Box 2119
' Environmental Protection Teaticket,MA 02.536
(508) 564-6813
f.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION n ^�� t.
/
Property Address: 31 Liberty Lane Marstons Mills Address of Owner: 6`
Date of Inspection:12/18196 (If different) f- � /,y9
Name of Inspector:John Gracl Robert Walker:8 Heathcllfr Rd.S.Dennis U
Company Name,Address and Telephone Number:
r
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 12118/96
The System Inspector shall s bmlacopy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B.C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.)
The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/15195)
One Winter Streel • Boston,Massachusetts 02108 e FAX(617)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 31 Liberty Lane Marstons Mills
Owner: Robert Walker:8 Heathclltf Rd.S.Dennis
Date of Inspection:12118/96
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four 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
Cl 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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an 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
cesspool.
SAS is In hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 Liberty Lane Marstons Mllis
Owner: Robert Walker:8 HeathcllftRd.S.Dennis
Date of Inspection:12/19196
D] SYSTEM FAILS(continued)
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. if the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
3
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 31 Liberty Lane Marstons Mills
Owner: Robert Walker:8 Heathcll f Rd.S.Dennis
Date of Inspection:12118/98
Check if the following have been done:
x Pumping information was requested of the owner,occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
nlaAs built plans have been obtained and examined. Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
x The system does not receive non-sanitary or industrial waste flow.
x The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered,opened,and the interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/15195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 31 Liberty Lane Marstons Mills
Owner: Robert Walker:8 HeathclBrRd.S.Dennis
Date of Inspection:12118196
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 9
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available: Na
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:U gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped: o gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1991
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane Marstons Mills
Owner: Robert Walker:8 Heathclif Rd.S.Dennis
Date of Inspection:12118190
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'8'H 5'7"W 4'10•
Sludge depth:0
Distance from top of sludge to bottom of outlet tee or baffle: 0
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:0
Distance form bottom of scum to bottom of outlet tee or baffle: 0
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.System should be pumped every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _ccncrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: nla
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
nla
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane Marstons Mills
Owner: Robert Walker:8 Heathcillf Rd.S.Dennis
Date of Inspection:12118196
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of con struction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: nla
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
n1a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
n1a
PUMP CHAMBER:
(locate on site plan).
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
Na
(revised 11115195)
7 r
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 31 Liberty Lane Marstons Mills
Owner: Robert Walker:8 Heathclt f Rd.S.Dennis
Date of Inspection:12118/90
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Na
Type:
leaching pits, number: H 10 leach ptt
leaching chambers,number:nfa
leaching galleries, number: nfa
leaching trenches,number, length: nla
leaching fields,number, dimensions:nfa
overflow cesspool,number:nfa
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The leach pit was empty at the time of the inspection.
CESSPOOLS:_
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: nfa
Depth of scum layer: nfa
Dimensions of cesspool: nfa
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: nfa Dimensions: n1a
Depth of solids: nfa
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PrivyComments
(revised 11115195)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Liberty Lane Marstons Mills -
Owner: Robert Walker:8Heathclirt Rd.S.Dennis
Date of Inspection:12119196
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
0
nnt'Cl
4
AC
3�
�1 (DC-
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
41-41 ._$. �. STABLELQCATION �y ` a�L SEWAGE # Ct I``'ISl�
`TILLAGE ASSESSOR'S MAP Cz LOT
INSTALLER'S NAME C PHONE NO. 3. O c'5 co
SEPTIC TANK CAPACITY I,Ovo �w l�atis
LEACHING FACILITY:(type) (size)_I,000
NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER J��d�•
DATE PERMIT ISSUED: 17 - 9.
DATE COMPLIANCE ISSUED: 1:4-
VARIANCE GRANTED: Yes No
33' 39'
zz'
Sod
La-� # q
I � �
9
G a
AMM
PARCELNo: "���a Fes$.... �.�.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
I TOWN OF BARNSTABLE
AVVIlra#ion for Disposal Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at
...... .. .j _9........�-- . ......- � ... a2a-
....- ...............
dd . t Noz_ ... . ..........................................
a Address
..............:1......_.....'S�......... ...
Installer Address
Type of Building 3 Size Lot........` E.d Bd..Sq. feet
Dwelling—No. of Bedroom ............................................Expansion Attic (Va Garbage Grinder (No)
aOther—Type of BuildingV0(7 •1__?0 No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .................................... -•-••• ----------------•----------------------
iqp
W Design Flow...............11Q....................gallons per eer day. Total doily flow____-__��_'�� --..-_gallons.
1p�U .� y ���� S y,;
W Septic Tank—Liquid capacity._._____._.gallons Length._._... .._. Width................ Diameter__:_____--_-•--- Depth_.1(�_.......
x Disposal Trench—No..................... Width...---.i...._._._.. Total Length__.......... . Total leaching area.................... ft.
1� , a �7
� Seepage Pit No...__._____/______.. Diameter....... .. ........ Depth below inlet.....6............ Total leaching area._._..._._ ....sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..................................................-....................... Date--......................................
Test Pit No. 1._ _ ...minutes per inch Depth of Test Pit----la...._.__. Depth to ground water--_/!!�4.a ._
44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
04 ---
t-•..... ........ _ y
O Description of Soil---•--�-• �•-4....................r`..................... ....... lQ .....x
W
----------------------------------------------------------------------------------------------------------------------------------------------•------------•--------•--•-••-•••----•---..............--
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
-------------------------------------------•---------------------------------------•-----------•-••---•------------------------------------------------•----------•---•-----------••-•--•---•---•••-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance Us been issueWbt e board of health. A
Signed --- d-� v (�
Application Approved By .............................................. ...............................................................----------
---------------------------------------
Dace
Application Disapproved for the following reasons: .... .................................................................. . . ....................................................
-------------------------------------- ----------------------- ----- -- ---------------- ------------------------ ---------------------------------------------------------------------------- -------- ......................
PermitNo- ------------------------------- -- ---- -- ------------------ Issued ------------------------------------------------------------------
`�� Dace
THE COMMONWEALTH OF MASSACHUSETTS F$s F//7/79
BOARD OF HEALTH
TOWN OF BARNSTABLE
AppluatUan for Ilisposal Works Tonohmrrion Ilermit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
Sam �tr _� �0.
a -- ----- - — —;/1?-=�?
ryaAddress
4 Type of Building Size Lot__ 7� d OU Sq. feet
Dwelling—No. of Bedroo _____-7__-____-------------Expansion Attic (N() Garbage Grinder (NO)
-_ Showers — Cafeteria p� Other—Type of Building _-oO o_1'�i� No. of persons-----------------__-- ( ) ( )
Other fixtures ------------------------- -
a --------- - - - --- - - --- -- - -- -----
W Design Flow________1 _-_------gallons per C day. Total daily flow_•-_- ��i„—____-gallons.
WSeptic Tank=Liquid capacity./ gallons Length--- 6_.--Width_y__!v_____ Diameter--- Depth_ /�_--
Disposal Trench—No.-----______Width---------------Total Length--------_ Total leaching area-__--sq.ft.
3 Seepage Pit No--- ------L-------- Diameter-------- ____-- Depth below inlet--k Total leaching area t.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by-----------------------_-----_--_ __�_—_-_—__-_ Date_---
- ---
a Test Pit No. 1 ___minutes per inch Depth of Test Pit_/% ___ Depth to ground water___Zt'd N,
fi Test Pit No. 2 —__minutes per inch Depth of Test Pit----------- Depth to ground water__--_-
O Description of Sort_�_�o
------------------------------------------------------------------------------------- -------------
V Nature of Repairs or Alterations—.Answer when applicable-------------------------------_---------_------------____-- --
Agreement: }
The undersigned agrees to install the a€oredescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued b e board of health
--
Application Approved By ------- -- ----- --- —-------
Application Disapproved for the folio ng reasons:
_ ----- - - -------- ------------------------------------------------------------------------------------------------ ---------------- --
Permit No_ - �=- r' �� --------- - ---- -— n" -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
arr#if CZ& of (iffoutpliance
TINS-IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( A or Repaired ( )
by -J J /sCG«----at -
L U 7 - -- 2 �1�1'_-- 1 ----------- --- - - -- - - ----
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No dated ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFA RY.
DATE------ 1 � _� 7i' %jl Inspector_- -�-=-- --- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No._�/--�Lk- TOWN OF BARNSTABLE F=
lan�l_ k� �wrn �an rrm�
Permission is hereby grantecL__V'`J�_
to (^Y� or Repair L ) an Indio ideal S e Disposal System
street 6 S
as shown on the application for Disposal Works Construction P -�t o._ � _
Bm.a of Health
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