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'' <L\, Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Verty Address
Wbara A Tarbox
Owner Oamer's Name
information is Arstons'Mills I✓ MA 02648 March 7 2017
required for every
page. CAR Town State Zip Code Date of Inspection
t►
CU
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information S/# to 13-9
filling out forms
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
VikA 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 DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes OF El Conditionally Passes ❑ Fails
Atigssgc
❑ Needs F o Eve DM io a Local Approving Authority
COUG NOWR N
N ,13 8
I` March 7, 2017
Inspector's Signat TFM INSPEG Date
The system inspecto 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•Page 1 of 17
R
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is .required for every Marstons Mills MA 02648 March 7 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.
-Go to Eco-tech.us for more info on septic systems.
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 th.e'septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltrationiontank.fail'ute is imminent. System will pass
inspection if the existing tank is replaced with a°orrnplyingseptic tank as approved by the Board of
Health.
* r ' t rCr t nt4 ,
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 ilable.
❑ Y ❑ N ❑ ND (Explain below) a '
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
41 v Title 5 Official Inspection Form
wi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8_
Property Address
Barbara A Tarbox
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 7, 2017
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):
i
❑ 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
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 176 Olde Homestead Drive Assessor's.Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 7 2017
_
page. Cityrrown 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 I well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5`ppm, pr.bvided 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
11 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 '/Z day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
t t
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is Marstons Mills MA 02648 March 7 2017
required for every t
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia'nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 7 2017
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?
® 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?
E ❑ 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?
P q p 9 P
® ❑ 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 7 2017
page. Cityfrown 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? 1 ❑ Yes Z No
Water meter readings, if available(last 2 years usage (gpd)): 279 gpd
Detail:
2015: 79,000 gallons 2016: 125,000 gallons Irrigation system in use
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:
l5ins.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
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner - Owner's Name
information is required for every Marstons Mills MA 02648 March 7 2017
page. Citylrown 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 .
t
❑. Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
+ wM 176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
owner Owner's Name
information is required for every Marstons Mills MA 02648 March 7, 2017
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: 23+ years Certificate of Compliance for a new leaching system was issued 8/24/1993 (Permit#
93-442 at Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
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 ofaeakage, etc.): .
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age" years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5'x 5'x 6-1000 gallon
Sludge depth: 6 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 Insipection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is required.for every Marstons Mills MA 02648 ..March 7 2017 -
_
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28 inches
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? As built card
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 every 2-4 years 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 ❑ 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.6116 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
M 176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is regt.fired for every Marstons Mills MA 02648 March 7 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal - ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official e Ins i
p
ct on Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is Marstons Mills MA 02648 March 7 2017
required for every ,
page. Cityrrown 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
'Owner Owner's Name
information is •Marstons Mills " ' MA 02648 March 7, 2017
_required for every
page. Cityrrown 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. A hole was dug into leaching pit stone and no effluent contact staining was observed in the
stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the
leach pit.
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
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is Marstons Mills MA 02648 March 7 2017
required for every ,
page. Cityrrown 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
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is.required for every Marstons Mills MA 02648 March 7, 2017
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 EC®=I�E I�
L Oo C A TDOo NNE
—OF SEPTIC COMPONENTS
—DISTANCES IN DECIMAL FEET
A 8
EMST§NG l 17 20
DWELUNG 2 27 28
176 3 33 24
A
8
NOT
1 Q TO
SCALE
Z SEPTIC W r Oo C T l n
—� TANK ¢
w
uj
D—BOX 2, THIS SKETCH IS O
na BEST VIEWED IN
PEACHOR FORMAT S�
508 364-0894
OLDE HOMESTEAD DRWE
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
information is Marstons Mills MA 02648 March 7 2017
required for every ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25+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: 8/23/93
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:
Town of Barnstable GIS maps
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above the
bottom of a witnessed test pit in which no water was encountered.Town of Barnstable GIS maps
indicate that the property is over 25 feet above nearby pond.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 176 Olde Homestead Drive Assessor's Map: 43 Parcel: 1-8
Property Address
Barbara A Tarbox
Owner Owner's Name
required for
is Marstons Mills MA 02648 March 7, 2017
required for every
page. Cityrrown 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
GEOHYDROLOGICAL PROFILE
— NOT TO SCALE
LEACHING
PIT
BOTTOM
F OF
ACHING IS\ LEACHING
ABOVE HIGH FIT
+ GROUNDWATER/
N
ELEVATION OF
ADJACENT POND
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN F HARNSTABLI3 OP 1113
'C t zd/ / l�� ec SEWAGE
VILLAGE A s yds ASSESSOR'S MAP & LOTJ`67-60I_60 Q
INSTALLER'S NAME & PHONE NO-
SEPTIC TANK CAPACITY __Z'6)_d
I.EACHING FACILITY:(type) / (size) Inge)
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 61)C, _
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED____—e-�'��_
VARIANCE: GRANTED: No__iz_��
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ASSESSORS MAP NO: /� DUL
PARCEL NO.: ,-,�-
No.. ...:-_ p �j
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........... .............OF...../Sa ArLo�.�,.1�-(-------------------------.--.-.-.-.------------
,. ApplirFatiun for Uiipnial Warks Tonstrurtiun Fumit
Application is hereby made for a Permit to Construct qO ) or Repair ( ) an Individual Sewage Disposal
System at:
.�. ..�. .�1 -. Qmea&Ad-_b1i4:tAf................. ...................................................
Location-Address or Lot No.
.. . l - -------------_------ - 1' C2r�,�. .�.....................................................
Owner Address
W a _
Installer Address
dType of Building Size Lot._L14.$061.........Sq. feet
V Dwelling—No. of Bedrooms-_-__>3..�.1�i .....................Expansion Attic ( ) Garbage Grinder ( )
`-1 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures .-----------•-•--------••--••••. -
W Design Flow..............5.5......................gallons per person per day. Total dailyo flow.._....._313.o..•....._.___._._..__gallons.
R: Septic Tank—Liquid capacity".10..gallons Length....$........ Width----4:2___..... Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.......... ... Total leaching area--------------------sq. ft.
Seepage Pit No----------)---------- Diameter....__..$___..... Depth below inlet....b_........... Total leaching area..A D.0....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by__.LA).M._.------- ld/l.LS1'1 A.",................... Date.......5/11810-................
aTest Pit No. 1----- .......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........................
-••-------------------------------------------••-----•-•-------•-------•-------•-•---........_....------......._........••--
Description of
Ux
Soil..... --,�,;�-_.__....o kI L-------------•--.
rue .-•
1--------------------•------------.----------------------------------------
W � _......N�. � ,
-----•-•------------------------------------------- --- ----------
U Nature of Repairs or Alterations—A�,ns�wer w en applicable________________ _�________________ .______ ��....__..._. ._
Agreement: 1,
The undersi;e,4ees to install the aforede cribed divid S age Disposal System in accordance with
the provisions of ITT
LE 5 of the State Sanitary de he un urther agrees not to place the sy m '
operation until a Certificate of Compliance has be Pis d by t iealth.
Signed•.......................1�.. •. -- . •............... ----. --• ..
D to
ApplicationApproved By--•-••......-• ....... •. ......... .......................... ............ --..._.......---- ---- --------
ate
Application Disapproved for the following reasons----------------•---•--------------------------------•-----•-•...-------- ...................................
------•-----------•-•-••-------------•-••-••••--••-•••----•----•--••--•--•-•-••-••------•-••-•-•---•-•-•--••-.....------•-••--•-••-----•---•-- - ---•-•. . •--••-•-•--•--•--••--•-••-----------
......"---•--Date
Permit No........--------•---...:..-�--•------• --.•-� Issued_.-- ------
(A��� 1119--11 ate
3 -
N .... ....... .....
THE COMMONWEALTH OF MASSACHUSETTS
7�7/1 BOARD OF HEALTH
r(J.W,_`L........---.....OF.... ............................................
Appliration for Diapaiial Marks Toustrurtion Vamit
Application is hereby made for a Permit to Construct jO ) or Repair an Individual Sewage Disposal
System at:
.................. 1".Ijka....................................................
Location-Address or Lot No.
P-a....................................................... .....................................................
Owner Address
. ..... .................
.................................. ...................................................................
Installer Address
Type of Building Size LotlA.,..303..........Sq. feet
U ooms.....3..i,�.,A.t......................Expansion Attic ( )Dwelling—No. of Bedrooms.... ._ Garbage Grinder (
Other—Type of Building ............................. No. of persons.................._.._.._... Showers Cafeteria (
Other fixtures -------------------------------- -
allons Flow............5-'-5........................gallons per person per day. Total daily flow.........3. 3_0......................gallons.
9 Septic Tank—Liquid capacityXl �1(<....gallons Length__.._....__._ Width._. ...... Diameter________________ Depth......._.._.._..
Disposal Trench—No-.................... Width....___.............
Total Length...._.... Total leaching y---------- eac area--------------------sq. ft.
Seepage Pit No--------------------- Diameter-------5.......... Depth below inlet.._ik............. Total leaching area.,9.0.0.....sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.Ahl)...... J. l .(.1......................... Date....__ .................
Test Pit No. I----X--------minutesperinch Depth of Test Pit.................... Depth to ground water-__-__-____---__-----__.
G�, Test Pit No. 2................minutes per inch Depth of Test Pit...._..........__... Depth to ground water------------------------
)....................................................................................................................................................
0 Description of Soil--- -F6a.'1.... .................... -------------------*-----------------------------------------------
W I -( 'c -- -.(.....C .( "i.1'�t I.................
...................................V__-.D.........ml UU.aj...5(1!.�I i ..V
U ........................... ..................................................................
---------------------------------------------------------- ...................................... ------------------------------------------------------------------------
U Nature of Repairs or Alterations—An�wer when applicable------ ......
.(--"—1 L_ 'P 1—1 ",:>CA rt :.,,IJ
....................................................._3..........................--------------------------------------------------------------------------------------------------
Agreement:
The undersigneh clt�
grees to install the aforedyscribe ndivi*l V/wage Disposal System in accordance with
T' 5 E the State Sanitary c
the provisions of M11 :, of ode he u e - yte further agrees not to place the sy tem
operation until a Certificate of Compliance has bee i used by e health.
_7
Signed ..... ............................... ........ .
7 . t at
ApplicationApproved By........................... .. ... ................................................... ........... -- ----
Date
Application Disapproved for the following reasons:...............................................................................................................
l I!
................................................................................................................ -------
Permit No....:`.... ..... ................... -------------- /3 Issued. - ...._....w vau
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........�Z4::�'?:-:..............OF......41'-x").a'ahl�..-44 ..........................................
At
uEntifiratr of Tautpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed i 6) or Repaired
by.......... ........&ZA-LIU-4
-------------------------------Installer-----------------------------------------------------------------------------------------------
............ I M'&
at......L42. 0.1,b......�-JlJtr...�. 04-d..... HA AZ).&I'Lo..........e.. ....................................
has been instilled in accordance with the provisions of TITIE 5 of The State Sanitary Code as- descr'�e4 in the
application for Disposal Works Construction Permit No ------ dated___.._ --------- ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA i ANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............... ................................. Inspector....................................................................................
q2. THE COMMONWEALTH OF MASSACHUSETTS
!S—1 JWQGC
BOARD OF HEALTH Pj
'bj
........ . ............................... low.....................0
FE ........................
N,o ... ... ......
Disposal Workii 0511mitrativit "prrmit
Permissionis hereby gra(ed�.... �' .l....... ............................................................................................
to Construct �C' ) or ReLair an Individual Sewage Didposal System
...........................
at No....:c't... . . ....... ....... --_-_--- ........
Street
as shown on the application for Disposal Works Construction Permit NS6?__T7(af?_ Da
te ...........
.............. .. .. ............. ....................
Board of Health
DATE.-- ..........
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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