HomeMy WebLinkAbout0108 OLD MILL ROAD - Health c)(o4-082 --'
No.... ..�........ FRic .................
THE COMMO[�'WEALTH OF MASSACHUSETTS
BOARD `OF HEALTH
NC�.n........OF........�1e-„ .'tu�`v ........... .....
Appliration for Dispaiial Workii Tanstrurtion Frrmit
Application is hereby made for a Permit to Construct 4.-<Or Repair ( ) an Individual Sewage Disposal
System at: Q \
-• •.•.ation-Address or t o.
s. .:...........SM..t.. ........... ?. �
.... ................
•V_ Own A dres_... ...... ................:..... ' �
Installer Address
JType of Building Size Lot............................S .
Dwelling—No. of Bedrooms...............•........................Expansion Attic ( ) Garbage Grind r
aOther—Type of Building ......................... No. of persons............................ Showers ( ) — Cafeteria
dOther fixtures ..--�------•---•------••••---••-------••------•----•••-•-•-------...--•-•-•--•-----•--••••-•--•• ..............................................
W Design Flow..........\VO.......................gallons per person per day. Total daily flow._........ . .®.............gallons.
;0� Septic Tank—Liquid capacity,®gallons Length................ Width................ Diameter................ Depth................
x P g g q
Disposal Trench—No..................... Width___.._...._.._._._.. Total Length Total leaching area_.._._______......._s . ft
Seepage Pit No------_-------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........... 4::W .......4�..-.v-`.&*"* ..... Date....s^awl "1.3:.....
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................
-•••.--------••-•
O
Description of Soil-------�----�-'.
.--•----•----
-----�-�A.ln---...--••�•---•--•---��. -5-�-v-- ----••--------------------- -----------------
----------
x ...•----•••-•...............•-•........ ---_---- . ...... ....................0 `,, p
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 Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
ig --.... ------- ..p Y�!_l.. ..........-- :� �..---..
ApplicationApproved By • ........ -.`-•------•------------------••--•-•-••-•-----•---•--.................__ .... ....
Date
Application Disapproved or the following reasons---------------------•--••--•-•-......-------•---•---•---•-----•----•----•-------•---------.Da•--••----•.....
-•--------•-------•----------------------•---•---.......------------------.....................----.......--•--.....................------•--.......------------------•-•------•--••-----....._.....-••--
Date
PermitNo....................................................... Issued-.......................................................
Date
s.< NO~.. ........�. FEs.... � ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..n........OF............ -•-----------------
.� lirtttion for Ui_qpoottl Vork,5 Tonotrnrtion Prrutit
Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal
System at:
....��, ._..... >>�...... 41,............. =M =----- ....... ............ .....................................................
L cation-Address .-- or t No
---
Ownez- Ac tress
we � -A--•----•-•-•-•-- a�n_... ...........................................
Installer Address
QType of Building Size Lot............................S .� `
U Dwelling—No. of Bedrooms............... ........................Expansion Attic ( ) Garbage Grind r (�)�
Other—Type of Building No. of persons............................ Showers
a YP g ---------------•----------•• P ( ) — Cafeteria
Otherfixtures -----�---------------------•--••------------•-------------------------------•--•-----.--------------•-•---•--- - •-•-••----
W Design Flow..........\\.0......................gallons per person per day. Total daily flow........... . .............gallons.
WSeptic Tank—Liquid capacity V35'gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No................ .... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
�2: Other ( ) g ( )
0-4 Percolation Distribution
Results Performed byin tank�a . ....... y Date..... .. .:. . 3......
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----•-•--- -- . ............
O Description of Soil.-----QZ.,. ... . ....------- ....:.-cx� ��---....1 :>: .v�-C=Vim...............:.._-V�^,.�.�,., �-ct.��-'
W •-•-------•---------------------------------------------------------------------------------------•----•--------------------------------`
U Nature of Repairs or Alterations—Answer when applicable e ...................................
--------------------------------•--'-------•------------------------------------------........----------....-•------------------.....------------------•-----•------•-------------------.....-••--•-••-•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI..i, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of%health.
a�.
•G rApplication Approved By_._.:".._'.�.-=-- --`--------------------------•----•----•-------._.......-•-•--'---•---•-- Date
Application Disapproved or he following reasons:-----•--------••----------------•---'-------•-•----......----------------------...............---.......---•----
-----•---••---•--•--....-•..................................•••-••---•••-'-•-------•------.._.......-•-•--•-•-••--........-••---••-•------•-•-•-•-••-------•--------•-•--•-•-•----•-•••---•---•--.._..._
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .�rvn..........OF............,� !'...`?.�.� �� L.....�
. .. ............................
(Inrtif irate of Tontliliatta
THIS IS TO CERTIFY, That thr—Individual Sewage Disposal System constructed ( or Repaired ( )
by...........�_-P---' c ....--•-------...4 ..I--------------------------••---- -...............-'----.........._...--•
Installer
at-•-••••••--•--.:-:.._.)t............V:;' ........ � 4 -----... .._... ..--------------. Uh O�c�M
has been installed in accordance with the provisions of TITLE r The State Sanitary Coda escribed in the
application for Disposal Works Construction Permit No_;..�':���-` •._ _ dated_..� . ,��............:...........
THE ISSU CE F THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM WI FU CTION SATISFACTORY.
DATEy {/o
e Inspector.. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ........OF............. ............ ;� d
No ..•-•..�Y?..... FEE.............•..........
Rapoottl Works TFUlatotrurtion "Permit
Permission is hereby granted......Q..'�...-ant- '............... .�---••----•-----------------------•--........................---•---__
to Construct (j,.-�r Repair ( ) an Individual Sewage DispoT4 S stem (V
atNo........ -_'s�.�:............ '.............. ......'-� , � ............ ..................° i '..\.� 1
Street --._ _::''.....
as shown on the a pli tion for Disposal Works Construction Permit No.. .. Dated..tY.Z.,/k_�................
Board of Health
DATE..... / ---•-
.......
FORM 1255 A. M. SULKIN, INC., BOSTON
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FAMkL`! - 3 BEOR0oM
,I ►JO -GARBAGE GANDER- '• '
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00o GAL. i
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ems• �
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F14CHARD � !ONESA.
c BAXTER no. 2,1 0
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SON
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P L.p,t`1 REF 6 2E N GE•
GERTI�Y THAT THE �-�rtDAT10�(SNowN
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IN'5Tf?-UMENT SU9.VE`( 'THE Q1=FSETS SL1ou1,D
NoT (3E 'v5E To C)ETEF-l^11.l APPLICP.►-4T
ul 22 15 08:32a p•1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison �
Owrer C�q
Owners Name
information is Marstons Miffs itr9A 02646 7-20-15 required for every
page. CityfTown State Zip Code Dale of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling A. General Information
on //��� a�utluugt►rrr�i
on Lie computer, %0��•ili OF Mq �zii,,�
1- Inspector:
sso'%
use only the tab •.•q
key to move your 0? .S4
cursor-do not James D-Sears _= ;- JA M ES ':m
use the return Name of Inspector key. y
CapewideEnterprises,LLC * .o�
'
�o
„� Company Name ,, F ��`..••
153 Commercial StreetNSpEG�`�����
Company Address
� —
� s1'tpee MA 02649
Cityrrown State Zip Code
508-477-8877 _ S1623
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
i
7-21-15
nspector'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 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. � I/� r Y
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{Sins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17
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Jul 22 15 08:32a p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. 108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information is required for every I�tarstons Mills MA 02648 7-20-15
page. City/Town State Zip Code Dale 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:
The system is a 1000 Gal. Tank 0 Box and pit.
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.
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*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):
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rams'3(13 Tile 5 Official Inspedlon Fort:Subsurface Sewage Disposal System•Page 2 of 17 i
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Jul 22 15 08:32a p.3
Commonwealth of Ma
ssachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
108 Old Mill Road
Properly Address
Deb Morrison
Owner Owner's Name
.information is required for every Marstons Miffs AAA 02648 7-20-15
page_ ChylTown state Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpslalarms 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).-
El 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):
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Th
e 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 lain below
❑ ND (Explain ) ,I
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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
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❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ns-31t3 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 3 of 17
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Jul 22 15 08:33a p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information is requ.red for every Marston Mift MA 02648 7-20-15
page;. Cityrrown State Zip Code Date of Inspection
B. Certification (cant.)
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 then 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:
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D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
1
❑ ® Backup of sewage into facility or system component due to overloaded or j
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 G" below invert or available volume is less
than %Z day flow i
t3ins-W13 Tice 5 ORdal Inspection farm:Subsurface Sewage Disposal System-Pape 4 of 17 t
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Jul 22 15 08:33a p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Ow-ier Owner's Name
i ati
required for a very MarstorTs s f1i4A 02648 7-20-75
page. City/Town State Zip Code Date of Inspection
B. Certification (cant)
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 1.00 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 fndicate either"yes"or"no"to each of the foffowing, in addition to the
questions in Section D_
Yes No j
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❑ ❑ 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 i
regional office of the Department. l
t5ins•3113 Title 5 Official Inspectlon Forth:Subsurface Sewage DispOSel System•Page 5 of 17
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Jul 22 15 08:33a p.6
Commonwealth of Massachusetts
- -- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information
required for every Marstons Mdrs MA 02648 7-20-16
page. City/Town 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?
E ❑ 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?
ED ❑ 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 1 F.3D2(5)]
D. System Information
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Residential Flow Conditions:
I
Number of bedrooms (design): NA Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
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!Sins-3113 Title 5 01ficlal Inspection Form:Subsurface Sawago Disposal system•Page 6 of 17
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Jul 22 15 08:34a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information is required for every Marstans Milis MA 02648 7-20-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and pit.
Number of current residents: 2
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 ears usage 2013-70,000Gais
g ( y g (gPd))' 2014-186,000GaIs
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seatstpersonslsq.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-3113 We 5 Official InspecWn Form:Subsurface Sewage Disposal System•Page 7 of 17
Jul 22 15 08:34a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owners Name
information is
Marsbns MUls MA 02648 7-20-15 required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancyluse: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 6/08-5110- 10/14
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: j
® Septic tank, distribution box, soil absorption system j
❑ Single cesspool
❑ Overflow cesspool
❑ Privy i
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❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) �(
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❑ Innovative/Alternative technology. Attach a copy of the current operation and i
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
C] Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
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Jul 22 15 08:34a p,g
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owrters Name
information
required for every Marstans Miffs MA 02648 7-20-15
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:
1983- Permit #83- 562
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"feet i
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.):
Pipeing is 4" PVC SCH 40 and SCH 20.
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Septic Tank(locate on site plan):
20" j
Depth below grade: feet
Material of construction: `
E
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
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If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth: f i`
15ms-3113 Title 5 official Inspection Fonn:Subsurface Sewaga Disposal System-Page 9 of 17 Ill
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Jul 22 15 08:35a p.10
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owners Name
information is Marstorts Mrffs MA 02648 7-20-f 3
requires for every
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
29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle 12
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-"rape
Sludge Judge
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 at working level. Tank and outlet cover at 20"below grade.W/inlet cover at 6"_ In and outlet
baffle's. No sign of leakage or over loading.
it
Grease Trap (locate on site plan):
Depth below grade: feet
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Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
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Distance from top of scum to top of outlet tee or baffle
i
Distance from bottom of scum to bottom of outlet tee or baffle
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Date of last pumping: Date I
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t5ins-3/13 Title 5 Official tnspection Farm:Sutosurface Sewage Disposal System•Page 10 of 17
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I Jul 22 15 08:35a p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r` 108 Old Mill Road
Property Address
Deb Morrison
Owner Owners Flame
information
required for every Marston MiUs MA 02648 7-20-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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: bate
Comments (condition of alarm and float switches, etc.):
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Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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15irts•3113 TiNe 5 Official lrepaction Form:Subsurface Sewage Disposal System•Page 11 01 17
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Jul 22 15 08:35a p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k"
108 Old Mill Road
Property Address
Deb Morrison _
Owner Owner's Name
information
required for every Marstons Mills MA 02648 7-20-15
page. Citylrown 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.):
D Box is'I 1"x 1'V'4 below grade (Black Plastic)wJone line out. Cement cover over box.Box
is clean and solid _ No sign of over loading or solid carry over.
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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 appwtenances, etc.):
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" 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): !
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If SAS not located, explain why:
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t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 !i
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Jul 22 15 08:36a p,13
Commonwealth of Massachusetts
ffimwA Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information
required for every Marstarts MUIS MA 02648 7-20-43
C /Town page. �Y 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.):
Leaching is a 1000 Gal. precast pit. Pit at 43"below grade w/cover at 8". Pit is dry w/clean, like
new wall's. No sign of over loading or solid carry over.
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
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Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ins•3N3
Trtla 5 Offidal Inspection Form:Subsurface Sewage,Disposal System•Page 13 of 17 f
I
Jul 22 15 08:36a p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information
required for every Marstaris Miffs MA 02648 7-20-15
page. CilyfTown 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.):
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(Sins-3/13 This 5 Official Inspection Form:Subsvrfaoe Sewage Disposal System-Page 14 or 17 i
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Jul 22 15 08:36a p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Systern Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information a Mc-h-sbons 11A�JI's MA 02648 7-20-15
required for every
page. Cityfrown 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 feast two permanent reference landmarks or benchmarks_ Locate aU wefts within 100 feet Locate
where public water supply enters the building. Check one of the boxes belvN:
0 hand-sketch in the area below
Q drawing attached separately
19.4=a
_ 4X _ AC S'
ID
-�"39
o C] 3
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15ins-Y13 TMe 5 0lraal bnspoction Form;Subsurt2m Sewage Disposal System-Pap 1S or 17 i
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Jul 22 15 08:37a p.16
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
reformation isevery
Marst�orts Mdit
quired for eve A/lA 0264$ 7-20-15
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth tolhigh ground water. feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Lot and area high.system in rear of lot 15' hi her then street Bottom of pit at 10'below grade.
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
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Jul 22 15 08:37a p.17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 Old Mill Road
Property Address
Deb Morrison
Owner Owner's Name
information is M3�(bR5
required for every MA 02648 7-20-15
page. Cdyrrown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 tN 17
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LO CAZO f el/ / E, C E ��RM�,T NO.
VILLAGE p'
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I N S T A LLER'S NAME i ADDRESS
® U I L D E R OR OWNER
DATE PERMIT ISSUED _ i _
DATE COMPLIANCE ISSUED 9�� �3
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COMMONWEALTH OF MASACHUSETTS -
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE Y00
Address of Owner: 130 ASHLEY DR CENTERVILLE MA.02632
Date of Inspection: 9/20/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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: 1012/00
The System Inspector shaliesystem
copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. 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.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,.
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE.
revised 9/2198 Pape 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE YOO
Date of Inspection: 9120100
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES: s.
X 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined",explain why not.
n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or`n'ot metal,is 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 complying septic tank as approved
by the Board of Health.
nla Sewage or or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
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
_obstrucfion is removed
_distribution box is levelled or replaced
n/a 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
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revised 9/2/98 Paoe 2 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE Y00
Date of Inspection: 9/20/00
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 the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I.-
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ Y P P Y P Pp Y
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless�a well water analysis 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,Method used to determine distance nta (approximation not valid).
3) OTHER
n/a
revised 9/2/98 Paae 3 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: , 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE Y00
Date of Inspection: 9/20/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
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 an 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 n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I 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.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:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large Sy,:tem)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply
well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of
the Department for further information.
revised 9/2198 Paoe 4 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner: JANE Y00
Date of Inspection: 9/20/00
Check if the following have been done:You must indicate either"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 _ None of the system components have been pumped for at.least two weeks 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.
a:
X As built plans have been obtained and examined. Note if they are not available with N/A.
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.The size and location of the Soil Absorption System on the site
has been determined based on:
X _ Existing information,For example,Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 1 5.302(3)(b))
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
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revised 9/2198 Paoe 5 of 11
SUB URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE Y00
Date of Inspection: 9/20100
FLOW CONDITIONS
RESIDENTIAL
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):n/a
Total DESIGN flow: 330 gpd r
Number of current residents:2 t
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO `
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/1NDUSTRIAL
Type of establishment: nla
Design flow: n1a gpd(Based on 15.203)
Bass of design flow: n/a
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: n/a
Last date of occupancy: n/a _.
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping: n/a
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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1983
Sewage odors detected when arriving at the site:(yes or no): NO
-evised 9/2/98 Paoe 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE YOO
Date of Inspection: 9120100
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 18"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed bytertificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 5'7"W 4'10""
Sludge depth: 2"
Distance from top of sludge to bottom of outletitee or baffle: 32"
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: n/a
How dimensions were determined: MEASURED
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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet:tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
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.)
n/a
revised 912/98 Paoe 7 of 11
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contin-jed)
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE Y00
Date of Inspection: 9120/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order: NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
• a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
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revised 9/2/98 Paae 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 61066 P082 L12
Name of Owner JANE Y00
Date of Inspection: 9/20/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(1)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT APPEAR TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nl'a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
, s
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 912/98 Paae 9 of 11
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 108 OLD MILL RD MARSTONS MILLS, MA 02648 M066 P082 L12
Name of Owner JANE Y00
Date of Inspection: 9/20100
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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revised 9/2/98 Paoe 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 108 OLD MILL RD MARSTONS MILLS MA 02648 M066 P082 L12
Name of Owner JANE Y00
Date of Inspection: 9120/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: nla
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
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revised 9/2/98 Paoe 11 of 11
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