HomeMy WebLinkAbout1387 OLD POST ROAD (CT & MM) - Health 1387 OLD POST �MARSTONS MILLS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Cz
M 1387 Old Post Road Assessor's Map: 57 Parcel: 26 r
Property Address pay
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is Marstons Mills MA 02648 October 3, 2017
required for every -,-,
page. City/Town State Zip Code Date of Inspection C1
Ur
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
� Company Name
155 George Ryder Road South
Company Address
Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
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 D,EP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes NOF44 ❑ Conditionally Passes ❑ Fails
❑ Needs F � E�u�ion `� e Local Approving Authority
COU A OWR y
o.1 28
q o October 3, 2017
Inspector's Signat FM INS?
Date
The system inspector s all submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pages 1 of 17
Y � �iA4—
-Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ac°M 1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address 1
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
page. City[Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes-. .,.,
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and 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.
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.
gig.
The septic tank is metal and over 20 years old* or the;se,ptFicytank�(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltratlon or tank-f6i[uu"rd is imminent. System will pass
inspection if the existing tank is replaced with a co'Mpiying,septic tank,as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurall'y-sorind,;not,leaking and if a Certificate of
Compliance indicating that the tank is less than 20,:yeats;,old is,auailable.
( p ) ter:
❑ Y ❑ N ❑ ND Ex lain below : N
t5ins.doc•rev.6/16 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
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owne- Owner's Name
iequiredfo is Marstons Mills MA 02648 October 3, 2017
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is Marstons Mills MA 02648 October 3 2017
required for every ,
page. CitylTown 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
co_liform 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 '/2 day flow
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
page. Cityrrown 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 gp_d.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
C Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c,M 1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
page. City/Town State . Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ZI No
Water meter readings, if available last 2 ears usage d 279 gpd
9 ( Y 9 (gpd)):
Detail:
2015: 98,000 gallons 2016: 106,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 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
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
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: owner
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is Marstons Mills MA 02648 October 3, 2017
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 28 years. System was installed at time of dwelling's construction in 1989.
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: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc'):
No evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1.5
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: 8.5'x 5'x 6-1000 gallon
Sludge depth: 4 inches
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
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 Winches
Scum thickness 1 inches
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined?
design plan
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. Maintenance pumping is recommended within 2 years and every
2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and
functioning as intended. No evidence of leakage in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
y ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required For every Marstons Mills MA 02648 October 3, 2017
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" El ❑ fiberglass ❑ polyethylene' Elother(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 co of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
copy P p 9
t5ins.doc•rev.6/16 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
c,M 1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is Marstons Mills MA 02648 October 3 2017
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
-' evidence of leakage into or out of box, etc.):
No adverse conditions observed.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 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
°M 1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
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.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. Pit was uncovered and found to contain 20 inches of effluent. No effluent contact staining
was observed at cover, interface or in overlying soils
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.doc•rev.6/16 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
°M 1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is Marstons Mills MA 02648 October 3 2017
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
_Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 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
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is Marstons Mills MA 02648 October 3, 2017
required for every
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
SEPTIC IMF® AT
ECO
L OO C A TOONSS
NOT -OF SEPTIC COMPONENTS
TO -DISTANCES IN DECIMAL FEET
SCALE A B
1 24.5 30
r 2 28.5 .33.5
3 '35 '51
4 61 96
EX§S T§NCB
DW1 CL UNO
0 1387
THIS SKETCH-IS
BEST VIEWED IN
A B COLOR FORMAT
1
1000 GALLON.
SEPTIC TANK
r'n
0 2 -,
m
LEACH
PIT a '�
DISTRIBUTION BOX S� •• ��
508 364-0894
OLD POST ROAD
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
ill
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1387 Old Post Road Assessor s Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If'checked, date of design plan reviewed: n.d.
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
previous inspection report
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database -explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design Ian on file with the Board of Health shows bottom of system to be 4 feet above the
pp 9 p y
bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS
Department records indicate that the property is over 20 feet above groundwater table
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1387 Old Post Road Assessor's Map: 57 Parcel: 26
Property Address
1387 Old Post Road Realty Trust-Judith P. Lothrop, Trustee
Owner Owner's Name
information is required for every Marstons Mills MA 02648 October 3, 2017
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
GEOHYDROL OGI CAL PROFILE
— NOT TO SCALE
I �
E
e PRECAST r� s
LEACH
PIT
41
O
N BOTTOM
OF
LEACHING
PIT
LEACHING IS
ABOVE HIGH
GROUNDWATER
GROUNDWATER ELEVATION
PER GIS MAPS
I
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
cOti1MONWEALTH OF.MASS AC9USFTTS
ExiCL-TIVE OFFICE OF EVV IRONNIENTAL AFFAIRS '
DEPART`1E�T OF ENVIRONNIE�TAL PROTECTION
ONE WINTER STREET. BOSTON. AtA 02106 E17-:S:•S:Oti
WILLIAM F.��LD•.a a r .:, TRL�I'CG>_
ARCri:O PALL CEL1L'CCI N` ._�_ DAN ID B STRLI
LLGavcor SUBSURFACE S"cWACE DISPOSAL SYSTEM INSPECTION FORM .... Comrrissiarr_
rn
5'? PART A " 'e _ w
U� P -CERTIFICATION .
Property Address, 43 j Address of Owner. I
Date of Inspection: :(If difiereat) �� �(�,Npp( A,%
Nance of inspector. ► �o .: <.- N2vJ13N�1`�,�'WI A-.
I am a DEP ap roved system inspector pursuant to Section 15.340 of Title S (310 CMR 13.000)
Company Namc&1 o �.r-st•r'a CIA �•,'r�Q., r�.� Q_M
Mailing Address: 2 o /3o�c C 37? H f�5f/oe2 /`>' 0 2C4-'7 .
Telephone Number: e-Se Z _4-L41;-
CERTiFICATION STATEMEIT
I cer:rN that I have pe•sonalh inspected the sewage da*asa! s\ster:at this address and that the iniormauon reported below~rtitr-ue. ac-.urain
NaEt.� ;
and c.omofete'a=. of the time of inspect on. The Inscec:x-i was pe^crmed bases as my training and experience to the,Fraper`tu~c�c�,a^d
maimenance of on-site sew•a;e dispasa; systems. The evverr:
' E3
_ Co-cit.cnaiN Passes �� i
_ %eecs Furthe- Eva!uano- Ev the Local Approving Authonn Y 22 1998
C�l
TABLE r
Inspect is Signature: Date: Qs,
,- A
i
T:ie SvS.e-r Ins:??:o- shad' subrm: a copy of this inspec:oer+ recCr, to the Apercvir.g Autheriry within thin%• 1301 darn cf ccmpJesir€,;his
inspection. It the svvem is a shared .\•stern a• has a de:-gn flow of 10.000 Inc' or greater, the inspector and the sys-,m c ner sha'1 subma
the re^.o^ to the noropnate reg-aral o lice of the De;arment of Envirenmenta' Frctencr.. The orig:na! should be sent tc the intern owns
and capes to the buyer- ii applicable, and the approving authorir\
INSPECTION SUMMARY: Check A, B, C, or D
.A.1 SYSTEM PASSES: .
I have not found any information which indicates that the system violate: any of the failure criteria as defined in 310 C.MR 13.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
H] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' se^.ion ne-d to be replaced or repaired. The systern, ucc
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes. no. or not determined (Y. N. or NDi. Describe basis of determination in all instances. If'not determined- explain why not.
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 (201 years prior to the date of the inspection:
the septic tank, whether or not metal, is cracked, struaurally.unsaund, shows substantial infiltration or exfiltration, or t:.n
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
a! approved by the Board of Health.
SUBSURFACE SEWAGE DISPOSAL SYSTF_14 INSPECTION FORM
PART A .
CERTIFICATION (continued) _
Property Addr.>iss; ,
Owner:
Date of Inspection:
Bl SYSTEM CONDITIONALLY PASSES (connn,,i'd-
Sewage backup or*breakout or high static water level observed in the distribution box is due to broken or obstructed
r uneven distribution,box- The system will pass inspection if(with a proval of th
• pipets) or due to a broken. settled e u � ! .e
Board of Healtht. Describe observations:
' broken pipe(s) are replaced . .; _ • . _ '
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed piped.:The system will pa«
insoec iori if twith approval of the Board of Health):
-'."broken pipets; are replace-777-7 d - • Y
=obstruction is removed a • �• .._..s.._ a�
C] FURTHER EVALUATION
' REQUIRED BY THE BOARD OF HEALTH:
O IS
Conditions exist which reouire furthe•evaluation by the Board of Health in order to determine if the s}•stem is failing to protect the
public health, saieti•and the environment.
1) SYSTE-M WILL PASS UNLESS BOARD OF HEALTH DETULMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cess000l or prnti is within 50 fee, of a surface water
Cesspool ar pri.1• it within 50 fee: of a bordering vegeated wetland or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPR1ATc', DETERMINES THAT
THE SYSTEM IS FUNCTIOti1\G'IN kMANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFtiY AND THE
ENVIRONMENT:
-The system has a septic tank and soil absorption system MASI and the SAS is within 100 fee, to a surface water supply or
tnbutan• to a surface water supply.
The system has a septic tank and soil absorption systern and the SAS is within a Zone I of a public water sup-)IV welt.
_ The syste-n has a septic tank and soil absorption system and the SAS is within 50 fee: of a private water supply well.
The syste-n has a septic tank and soil absorption system and the SAS is less thar. 100 fee: but,50 fee or more from a
private water supply well, uniess a well water analysis for coliform bacteria and volatile organic compounds indicates ths.
the well is free from pollution from that facility and the pmserice of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) . OTHER
(r.viSad 04.2313:1 page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A as. ..
CERTIFICATION (continued) -
Propert} Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either "Yes" or 'No' as to each of the following
I have determined that the system violates one or more of the following failure criteria a< 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. WP .
Yes No
Backup of sewage into facilrty,or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge`or pondrng'oi effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Stoat !round level in the drstrrb.,tron boa above outlet invert due to an overloaded or clogged SAS or cess`poo;.
Liaud depth in cesspool is less than 6" below invert or available volume is less than 1/2 day floe.
Reouired pumping more than. 4 times in the last year NOT due to clogged or obstructed pipe's
Number o'times pumped _ - • _ - . .
Any portion of the Sod Adsorption System, cesspool or pnv,)• is below the high groundwater eievation.
Ar., por::on o'a cesspool or privy is w•rthir. 100 feet of a surface water supply or tributan to a surface water supply
Any por;ron of a cesspoo' or prn-,• is N rthir. a Zone 1 of a public well.
Am pc^ro- o-a cesspool or pnvti• is within 50 feet of a private water supple well
Any por,or. o:a cesspool or privy is less than 100 feet but greater than 50 fee: from a private water supply well with no
acceo:able v�ater qualm analysis. If the well has been analyzed to be acceotabie. anach copy of well water analysis for
cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: `
You must indicate either -Yes" or "No- as to each of the following.
The iolio,mg criteria app;% to large systems in addition to the criteria above:
The system serves a facilm with a design flow of 10,000 gpd or greater (large System; and the system is a significant threat to
public hea!th and saier� and the environment because one or more of the following conditions exist.
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)
The owner or operator of any such system shall bring the system and facility into fu11 compliance with the ground water:treatment program
requirements of 314 CMR..3.00 and.6.00. Please consult the local regional office of the Department for-funhe-r.iniormation:---
(r•va�•d 0�/2S/97) Page 1 0r 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM
PART,B
CHECKLIST
$001
Property Address_ 1
Owner: "ftV_%P li
Date of Inspection:�`�(�L� F _ .r. • .. •,
Check if the following have been done: You must indicate either "Yes"or'No' as to each of the following:
Yes N
- Pumping information was'pro"vided'by the'owner, occupant, or Board of Health.
re
Norte 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 pan of this inspection.
pt4_zwjk plans have been co,a4ned and examined. Note if they are not available with h'A.
The iacalir� or dµ'eliing was inspected for signs o-sewage 'back-up.
_ Tne system does not receive non-sanitary or industrial waste flow.
_ The site %%as inspected for signs of breakout.
_ All symeT component;. eaclud4ne the Sod Aosorpuon System, have been located on the site.,
_ The septic tank manholes µere uncovered. opened. and the interior of the septic tank was inspected ion condition of
baffies or tees. materta; o• 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 "
_ The iac.hm o%%ne- ',ano occupants. tf drfteren: trom oµ•nert were provided.with miormation on the.prope• maintenance of
Sub-Suriace Disposal System.
Existing information. Ea Plan at B.O H.
_ De;ermined to the meld tr am of the failure criteria related to Pan C is at issue, approximation of distance is
unaccextabie 115.302:3t:b4l
.11
(r•v1••d 01/:5/5'4 P•g• 4 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propert% Address:� \3� O
Owner: 0IR60,1
Date of Ihspection:
FLOW CONDITIONS -
RESIDENTIAL:
Design flcN g.p.d.,rbedroom for 5.4,.5 -
Number of bedrooms I-11) '
Number o:current residents
Garbage 2•:'der (yes or no.: Q
Laundry cor—ected to system (yes or no! _.
Seasonal use ayes or no!:�.)
Water meter readings, if available (last two Q11 year usage tgpdt: �.nuJ UStA�ti
Sump Pump Ives or nor
La.-. date o-occupancy _c�U�+Y�Q)I;, �1-)?><lJ 11$pq• (_,
COMMERC i;AUNDLISTRIAL:
Type of establishment
Design fio%. ea!ionyda\
Grease crap present tees or no_
Industna! %%aste Holding Tani; oresem. Ives or no_ -- -
':on-sancta,\-waste discnargec to the T!tje 5 wstem ;yes or no
%%ater meter readings if availabie
Las:pate o: a
CTHER: .Describe
Last sate of occudanc.
GENERAL INFORMATION -
PUM?ING RECORDS and source of tnforrha�t,or
System pumped as par, of inspection: Ives or no._N,
If yes, volume pumped ¢allons
Reason for pumprrtE -
TYPE OF SYSTEM
Septic tank/distribution box!soil absorption system
Single cesspool
Overflow cesspool
Shared system (yes or not (if yes, attach previous inspection records, if any) ____._ -
I/A Technology etc. Copy of up to date contract?
Other - -.
APPROXIMATE AGE of all components, date installed (if known) and source of information: 06 '
Sewage odors detected when arriving at the site. (yes or no)
(revised 04/25/91) Page S of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
SYSTEM INFORMATION (continued)
Property Addresis: . f 05T
Owner: H{f 14o,
Date of Inspection: ,rl���O •,° " � -'- _..__-_._._..,.�.,...
`I I
BUILDING SEWER:
(locate on site plan)fib
Depth below grade. r -•
Material of construction. cast iron _40 PVC _other (explain` " t
Distance from private water supply well or suction Ire
..._......... .a_,.......w._.n.._...--....�.............ter' p.-......+. ....hi1.-_._...�A--+M� ..n. .-- .:. a. .
Diameter
Comments: (condition of joints, venting, evidence of leakage. etc.)
SEPTIC TANK:46
(locate or site pI �
Depth below grade
Material of construci,on- }�concre:e _meta _Froerglass _Polyethylene _othertexplain
If tank is meta:. Iis: age _ Is age con:irmec o% Ce^•iica:e o-. Compliance.=Oes.-No
Dimensions
Sludge depth
Dtsiance from top o:Y -t swage to bono- of ou:le: tee o, ba�ie �
Scum thtckness��-._l _•.__.. -.....`.. .- _ ._.._...._._._ __ __.- ._._ __.. . _ .._. _..
Distance from top of scum to top o; outle: tee or ba-:;.e 1 ��
Distance from bottom o-'scum to boom o,outlet t e c- ba�.e .
How dimensions were determined
Comments
trecommendation for pumping. condition o' inlet a islet legs or baffles. depth of liquid level in relau n to outle i yen str al
inte pry, evidence of lea)�e, e:c.) V E 2
GREASE TRAP:/ y
(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:
-" (recommendation for pumping, -condition of inlet and outlet tees or baffles, depth of liquid level in relation-ta-ou%let invert,-structur-al-- --
integrity, evidence of leakage, etc.)
(re%•_aad 04/25:97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM IrNSPECTIO'N.FORA
PART C
SYSTEM INFORMATION (continued)
Properh A.ddress:�13$1
O%ner:�(,W�,�tJ
Date of Inspection:
TIGHT OR HOLDING TANK: -rank must be pumped prior to, or at time, of inspections,
(locate on site plan,
Depth below grade.
Material of construction.- concrete _metal Fiberglass _Polyethylene _other(explain)"
Dimensions: -
Caaacrr•: gallons
Desrg^:ilo" galronsloa.
Alarm level A:arras in %korking orde• — Yes. _ No
Date of previous pu"rnping
Comments
(condirron of inlet tee. condition o- a!a,rr. and float switches, etc.) -
DISTRIBUTION BOX:
iloca.e on site p-a-
De:�:h o`Iiouid le%e' a00%e ouue: ime^ G �6U���J1fht!'i1
Comments
mote r.'leve! and distrrburor rs Ku. evidence of solids carryotoqr. evidence of leakage into or out of boa, etc.)
Q 1210•c5`1o1kr&I N4 �U C�tatn
PUMP CHAMBER:_.
(locate on site plan.
Pumps in working order: (Yes or No,
Alarms in working order (Yes or No
Comments: _
(rote condition of pump chamber,'condition of pumps and appurtenances, etc.)
(revised 04/25!97) Page 7 of 10
_�...
SUBSURFACE SE'WACE DISPOSAL SYSTEM INSPECTION' FORM
PART C
SYSTEM INFORMATION (continued) '
Property Addr-ss: k2a,; l0(a
Owner: W1,notR %1
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): U16
(locate on sne,plan, �i possible: exca. ion not requ�red.'but'may be approximated by'non-rntru'srve methods
If not determined to be present, explain:
Type:
leaching pas. number. loX U�
leaching chambers, number:_ -
leaching galleries. number:
leaching trenches. number length:
leaching fields. number, d.rnensior.s
overilow cesspool, numoe- _.
Alternative system
Name of 7ecnnotog\•
,. .
Comments
mote condition of soil-s!gr"s of hv&auGc failure, leve' of ondrng" oaditi of tetation. etc.t,.
61h CA
CESSPOOLS:
(locate on site plan.
numbe• and coaiigura:,or.
Depth-top of liquid to inlet r,inv
A p �Q e
Depth of solids lave-
Depth of scum layer .
Dimensions of cesspool - -.-materials of of construction
Indication of groundwate-
inflow tcesspool must De pumpec as par, of inspection}
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.):
(revised 04/25/97) Page I of 10-
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SUBSURFACE SEWAGE DISPOSAUSYSTEM INSPECTION FORM
PART C
1 SYSTEM INFORMATION(continued
Propem Addreds: �13�7 O�GI FC15�
Owner:
Date of Inspection: Its
(7.
(
O
SKETCH OF SEWAGE DISPOSAL SYSTEM.
include ties to at least rwo permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house!
o �
m Z _
A � I
lr•va••d 0�'25!571 page 9 of .10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI01 FORM
PART C
SYSTEM INFORMATION (continued)
GG
Propem Address• 3D7 014 1 PaT
Owner: 01i,00)
Date of Inspection: .
1
Depth to Groundwater±I7,Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation o;Site (Abutting property. observation hole, basement sump etc.)
Determine it from local conditions
Cnec'k %%ith loca' Board o• nea!:r
Chec: FEMA macs
Cheo pumping records
Check loca' irs:alle-s
Lse
r I
Describe in \cx o••- v-xcs ro,.• \o_ es:ao;:shed toe Cround-sate• Elevation (Must be cor-pie:ed
&TairJ Cd �otA ��r (46 60 ���a� stT� p[cz-tV.
f .
Page 10 of 10