Loading...
HomeMy WebLinkAbout0228 OLDE HOMESTEAD DRIVE - Health 228 Olde Homestead Drive, Marstons Mills 6A�- i, Commonwealth of Massachusetts as O Title 5 Official Inspection Form ++ I=I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r1 l 70 Waterfield Rd i-•,a 'roperty Address N.7 Marcus Gherardi l�ry Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 M" page. City/Town State Zip Code Date of Inspec`1 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. A. General Information 1: Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 - Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S 13971 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 Ev on the Local Approving Authority 1-25-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP).within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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 Commonwealth of Massachusetts a=1 Title 5 Official Inspection aForm ! �I Subsurface Sewage Disposal System:Form -Not for Voluntary Assessments 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name inquired for is Osterville MA 02655 1-25-18 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/alrvays•complete all of Section D A) System Passes: ® 1 have not found 'any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 orrepair, as approved by the Board of Health, will.pass. ; Check the box for"yes", "no" or "not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): , t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 2 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 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): I ' ❑ 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): _ S 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 '❑f Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '. 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to.a surface water supply. ' El The system has a septic tank and SAS.and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or".No"to each of the following for all inspections: Yes No, ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ' ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid•level.in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less '' than %day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts .a Title 5 Official Inspection Form J, ,�N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 page. City[Town State Zip Code Date of Inspection R. 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. ❑ ® An portion of a cesspool or privy is within 50 feet of a private water supply well. Y P P P �Y P PP Y ❑ ® 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.] ❑ ® h The system is a cesspool serving a facility with.a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. l 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. J 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. :r 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 :a1 J., Title 5 Official Inspection Form ,, � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F i Wate I 70.,_�.�,.. rfie d Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 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? ® . ❑ 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, t 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): 4_ Number of bedrooms (actual): 4 DESIGN flow based on.310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ,a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Waterfield Rd Property Address Marcus Gherardi . Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a grinder? El Yes ® No garbage Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? . ; ❑ Yes ® No Last date of occupancy: 1-2018Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpa) • r 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? y ❑ 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 . r lai Title 5 Official Inspection Form, =� 11-1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 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: r " Source of information: Owner--pumped 2yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Priv y ❑ 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.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Rage 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form r. Subsurface Sewage Disposal System Form -N ot for Voluntary Assessments 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 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: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 48" feet Material of construction: . ❑ cast iron ® 40,PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): Depth below grade: 40"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: ' 1500 gal Sludge depth: 10" t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 4 i _ Commonwealth of Massachusetts :a=1 Title 5 Official- Inspection Form : I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 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 22" r:> Scum thickness `. 0 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts �aa Title 5 Official. Inspection' Form 1II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L; lt _ !a/ 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons r Design Flow: . r ' 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form' R! i;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,a 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 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 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.): Good condition with water at working level and no sign of back-up from field. 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.5/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts al Title 5 Official Inspection Form bil I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 a: 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 page. Ciy/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6-Cultec 330's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/Iname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cultec leach field in good working order with no sign of back-up into d-box or surrounding stone. 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.1o6•rev.6/1, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts : Title 5 Official Inspection f, p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Waterfield Rd , Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 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.): 4• } t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `� �.;�!•� 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is required for every Osterville MA 02655 1-25-18 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) . . I . . 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 Q Ck " 7 F t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts � l Title 5 Official. Inspection Form . I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 70 Waterfield Rd Property Address Marcus Gherardi Owner Owner's Name information is Osterville MA 02655 1-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water . r ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, 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: Original design plans show no groundwater at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r= — Commonwealth of Massachusetts I._ Title 5 Official Inspection Form -i-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Waterfield Rd Property Address — ----- Marcus Gherardi Owner Owner's Name information is required for every- Osterville MA 02655 1-25-18 page. Ci-yfrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts - a= Title 5 Official Inspection Form t 1 f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 228 Olde Homestead Dr Property Address + Corey Mackey Owner Owner's Name a information is Marstons Mills '� MA 02648 1-26-18 i . required for every .• - page. City/Town State Zip Code Date of Inspection;31 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. A., General Information 51 /a80� 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 16.000).The system: ' ' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluati-n by the Local Approving Authority 1-26-18 I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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 Commonwealth of Massachusetts Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check'A,B,C,D or E 1'4/ways 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass iinspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): , . t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts - :a=1 Title 5 Official Inspection.form r� ' �A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 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 ja 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. I.'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 fin` • n , 'h.. r Y Commonwealth of Massachusetts =1 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr a Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills ►s-• MA 02648 1-26-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if'any) determines that the system is functioning in a manner that protects the public health, safety and environment: , I ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 10b feet of a surface water supply or tributary to a surface water supply. ❑' The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or'!No"to each of the following for.all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or i clogged SAS or cesspool' , 0 ® `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 Y2 day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 page. Cftv/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well'water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section-D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection " El El 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 �,+ t Title 5 Official Inspection Form -� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 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 previous1wo 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) ® ❑ i 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 e< 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: k Number of bedrooms (design):. 3 Number of bedrooms (actual): 3 r DESIGN flow based on,310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 1, t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ; :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A, 228 Olde Homestead Dr F Property Address Corey Mackey Owner Owner's Name information is Marstons Mills MA 02648 1-26-18 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? - ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 1-2048 - Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based+on 310 CMR 15.203): Gallons per day(gpa) 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17' Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form I��1 1-2I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 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: N/A 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 :a=1 Title 5 Official Inspection ,Form JAI Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments �F U4;!,i 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): e 14" Depth below grade: ; feet Material of construction: . ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private Water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate'on site plan): . 8 Depth below grade: 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: 1000 gal 12° Sludge depth:. t5ins.doc-rev.6/16. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Cilde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 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 20" :. Scum thickness 0 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. a • 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts _ :+ Title 5 Official Inspection Form yW.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a �W✓ 228 Cilde Homestead Dr P�operty Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts 1a=1 Title 5 Official Inspection,form IfA Subsurface Sewage.Disposal System Form -Not for,VoIuntary.Assessments 228 Olde Homestead Dr , t J Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 r page. City/Town State Zip Code Date of Inspection D. System Information (cont.) F �- 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.): Good condition with water at working level and no sign of back-up from pit. 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 a=1 p, Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr ° Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Type: , ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: y ❑ 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.): Leach pit in good condition with with water level and stain line at 30" below inlet invert. 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts +I �� Title 5 Official Inspection _Form 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 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 .a=1 Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �c 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 *L 71 At r: wo 40 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts fy Title 5 Official Inspection. Form ' 4 Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) : 'Site'Uam ❑ 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 frorri 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: USGS and town maps show groundwater at gretare than 20'. a 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 :I n. Title 5 Official Inspection Form P,;-1 :Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u�.;#!✓ 228 Olde Homestead Dr Property Address Corey Mackey Owner Owner's Name information is required for every Marstons Mills MA 02648 1-26-18 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 I ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Ii Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM sV•,a 228 Olde Homestead Dr - ~ 'Property Address earl Leone Owner Owner's Name information is Marstons Mills MA 02648 5-9-15 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information .y 6 �� 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ .Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-9-15 Inspector'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. W t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Ili Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 549 15 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of,Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection. Form b - Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments .228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) I ' ❑ Pump Chamber pumps/alarms not,operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y' ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or' privy is within 50•feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the'Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: . , ❑ The system has a septic tank and soil absorption..system (SAS),and the SAS is within „ 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ .The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 ® 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 Y2 day flow t5ins•3i 13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 page. City/Town . State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the.Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply .❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 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? ® ❑` 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. ® E Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions:, Number of bedrooms (design)': 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15. page. Cityrrown State Zip Code Date of Inspection D. System Information M Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: ti Sump pump? ❑ Yes ® No Last date of occupancy: 5-2015Date 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official .Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 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: N/A 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):•f t5ins-3/13 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 , 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 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: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 14" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): � 11 Depth below grade: 8fear 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: 1000 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 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 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments qM , 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ' Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspectionform Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y f 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 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 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.): Good condition with water at working level and no sign of back-up from pit. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - ,m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) - Type: ® leaching pits number: 1-1000 gal ❑ 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.): Leach pit in good condition and empty at inspection with stain line at 36" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a °M 228 Olde Homestead Dr Property Address . Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 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-3/13 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 228 Olde Homestead Dr P-operty Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 page. City(rown 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 . t 4 {. . LIP T qqq a i f t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is Marstons Mills MA 02648 5-9-15 required for every ' page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) - Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed- Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-'explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Olde Homestead Dr Property Address Carl Leone Owner Owner's Name information is required for every Marstons Mills MA 02648 5-9-15 page. Cftyrrown 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 I ® 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 of 17 F l T4 W T,Qf-BARNSTAJL� LOCATION VILL,i�CrC cirs Z�S �SSFSs�11t'S.MAI'$G L(}T INSTALL '5 NAt &��tOME N0 sF.I C TA141S CAPACI't. LEAt;gJIl+iG 1�Q,CIIT%"Y' (�y��) ND 0f i )Rooms 7777, IIitJIL,I B I OR OVIMR, .._._� P' gTI� 'IE Ct�PJ�i�1fS/�SVG'• 1p�.T :,� . iJ �:' �.. 5ePAM 04 I9�fi�nnee T3etvr en tlae Maximum l djusiecFGtautsclw�tet�fibie la tl c Batton atetwhihit.. d ity, :'... Ivcs1 0 r SuNVly Flail'us�cl d�ea:hire 1?aoaltty er►g+ alis exist as alas ar Mtblil2pR y) I?cti cy �r�/et�ac►d aqd Leacl_intt i+�cti¢y(if any waliand5 exi&4 � , �vi fl11j�:p0 fGe¢at tej►aiiing 4'uclli�ty� urnishnc4 tsy `�, 1 c,cfC t m Commonwealth of Mossochusetts - John Grac - - Ezecuwe Office of ErMronmen�tal Affair D.E.P..Title VSeptic Inspector. s' _ _ , _ - D�: ®� �Mt . - P.O.Box 2119 = 1p o Teaticket,.MA 02536 - Enviroa�enental ]Protection _ _ (508) 564-6813 - -- 12 - SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM i RT A _Q CERTIFICATION �° a - lit.© SEP Property Address: 226etawomesteadDr.MarstoniHllls Address of Owner: Date of Inspection:9111196 (If different).- ` d Glover Box 333 Marston Mills Name of Inspector:John Gra _ CP Company Name,, ddreis and.Telephone,:Number . ICA CERTIFICATIOM.STATEMENT I certify that t 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.properfunction and maintenance of on-site sewage disposal systems. The system: - I x_ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature; - : • Date:.9111196. The System Inspector shall submit a copy of"this inspection report to the Approving Authority within thirty(30)days of completing this inspections.. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the.appropriate regional office,of.the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer; if applicable and the approving authority. INSPECTION SUMMARY: Check A. B.C,or D: A] SYSTEM PASSES: . X I have not found any information whichindicate.s that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or-more system components need to be replaced or repaired. The system,upon completion. of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y,N,or ND). ,Describe basis of determination in all instances. If "not determined", explain why not.) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of,Heatth_ (revised11115195) One Winter Street . Boston,Massachusetts 02108 . FAX(617)556-1049 • Telephone(617)292-5500 1 N _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOWFORM PART"A : CERTIFICATION (continued) Property Address:..2280Id.Homestead Dr.Marston MIOS Owner. _.. Glover:.Box 333 MarWOn,M➢15 -.Date of inspection'9J11196 Sewage backup or breakout or highstatic water level observed in,the distributiorr box is due to a broken, - — : settled or ureven.distribution box. The system'will pass inspection if(with approval of the Board of Nealth): broken p'ipe(s.)are'replaced. - obstruction is removed ,F distribution box"is leveled o replaced' - The system required pumping more than.four times a year due to broken orobstructed.pipe(s). The system will pass inspection if(with approval of,the Boardof Health) _ ken;pipe(s)are replaced ob§traction is removed 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER'WHICH-WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is-within 50. Jeet.of a surface water Cesspool or privyis within.'S0 feetof a bordering vegetated asalt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES. THAT THE SYSTEM IS FUNCTIONING IRA MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic.tank,and soil absorption system and is within 100 feet to a surface of water.supply or'tributary to a surface water supply.' The system has a'septictank and-soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and.soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil,absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: '. I have determined that the system violates one or more of the following failure criteria as defined in + -310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what wid be necessary to correct the-failure. Backup of sewage in facility or system component due to an-overloaded or clogged SAS or cesspool. . Discharge or ponding of effluent to the surface of the ground orsurface wraters due to an overloaded or clogged cesspool. SAS is in hydraulic failure.. (revised 11f15195) 2 SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) - Property Address: 228 Old Homestead Dr.MarstonMUs Owner: Glover:Box 333 Marston MIAs - - Date of-Insp.ection:.919.1196. = _ D] SYSTEM FAILS(continued) - - Static liquid level in the distngn box above outlet inverf due to an overloaded or clogged SAS or cesspool. Liquiddepth in cesspool is less.than 6"below invert_or available volume is less than i72 day flow. Required pumping more than 4 times in the:last year`NOT due to clogged or obstructed.pipe(s), Numbers of times pumped z' - -.Any portion of the-Soil Absorption System, cesspool or privy is below the high,groundwater elevation. ..Any portion of a cesspool or p1lvy,is within 100 feet of a`surface water supply or tributary to a surface water supply. . Any portion of a cesspool or-privy is Within a Zone 1.of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any,portion of a cesspool-or privy is less than 100 feet but greater than 50 feet from'a private water supply well with no acceptable water quality analysis. if the well has been analyzed to;be acceptable, attach copy of well water analysis for . coliform bacteria, volatile orcric compounds,ammonia nitrogen and nitratd nitrogen. E] LARGE SYSTEM FAILS: The following criteria appiy,to large sys m. s in addition to the criteria: The system serves a facility with adesign flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and.the enviromnent because one or.more of the.following conditions exist: the system.is within 400 feet of a,surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located-in a nitraagdn;ssnsitive area(interim Wellhead Protection Area(1WPA)ora mapped Zone II of a public water supply:well) The owner oroperator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of.314 CMR 5.00 and`6,00. Please consult the local regional office of the Department for further information. (revised 11115195). 3 : r n y � . - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART B CHECLIST Property Address:.228 Old Homestead Dr.MarstonlViills - Owner: Glover:Box333MarstonMs - Date of Inspection:9f1U96 Check if the following have been done ' - X Pumping information was requested of the owner,occupant and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of'water have.not'been introduced into the system recently or as part.of this- inspection- n(aAs built plans have been obtained and examined. Note if they.are not available with N/A.: X.The facility or dwelling was ins.pected.for signs of sewage back-up .X .The'system does not receive non-sanitary or industrial waste flow. X The site was inspected for sig*:s 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 ofahe septic tank was inspected for-condition of baffles or tees;material of construction, dimensions, depth.of liquid, depth of sludge, depth of scum. X The size and location of the.Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11I15195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - . - PART C, - -: SYSTEM!INFORMATION Property Address: 228 Old-Homestead Dr.-MarMnMills Owner: Glover:Box 333 Marston MUls _ Date of1nsgection:9111196. FLOW' - ONDITIONS RESID€NTIAL.- Design.flow: 33ii gallons J, . - Number of bedro5ms: 3 Number of current residents: 2 Garbage grinder(yes or no): No _ Laundry connected to system(yes or no Yes - Seasonal use(yesor no): No Water meter-readings, if available: nla - Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow;,a �galions/day Grease trap preseft ayes or no) No Industrial Waste;-folding.Tank present: (yes:.or no) No . Non-sanitar waste discharged to the Title.S system:(yes or no)No Water meter readings, if available: rVa - Last date of occupancy: nla OTHER: (Describe) nla Last date of-occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information System has not been pumped in the last two years:. System pumped as part of inspection (yes or no)Na If yes,volume pumped: 0 gallons Reason-for.pumping: n1a TYPE OF SYSTEM. X. Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool _ Privy Shared system(yes or no) dyes, attach.previous inspection records,if any.) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1988 Sewage odors detected when arriving at the-site:(yes or no) No (revised 11115195) 5 �A PS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM: — - PART.0 - SYSTEM.,INFORMATIONI(continued) - Property Address: 228 old Homestead Dr.MarstoaWls - - - - - Owner:. Glover.Box 333 Marston MillsDate of.lnspection:9111196 SEPTIC TANK X (locate on site plan), Depth below grade: a" Material of construction:X concreate. metallFRP other(explain) Dimensions:L 8'6"H 5'7"W 4'10'...—. - Sludge depth:8" Distance from top-.of sludgei to bottom of outlet fteor baffle: Scum thickness:u Distance from top of scum to top of outlet tee:of baffle:s' - Distance form bottom of scum to bottom of outs#tee or baffle: o comments: (recommendation for pumping, condition of inlet<and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity: evidence of leakage,etc.) , Septic tank and all components are structurally sound Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site pian), Depth below grade: nta, Material of construction: _concrete metal- FRP_other(explaih) Dimensions: nla Scum thickness;nfa Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: nia - 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.) Na (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- _ - - - SYSTEM IPTFORMATION(continued)-'__ Property Address:,228 Old Homestead Dr.NkzsM Mills. __..�— ...:,..._,.«_Glover.-.-Box•333•Macstote6ffi� xv ,: _ _�._- . Date of Inspection:9111196 _ -TIGHT.OR-HOLDING.TANK. (locate on site plan) - Depth below gr2de: n1a - Material of construction: concrete meta6_FRP other(explain) `Dimensions: Na Capacity: nip gallons Design flow: Na gallonsLday Alarm level: Na `Cottiments` :' (condition of inlet tee, condition of alarm and float switches, etc.) 1 Na DISTRIBUTION BOX: X (locate on site plan) Depth of liquid•ievel above outlet invert: Liquid leYel with bottom of pipe _ Comments: (note if level and distribution is equal, evidence of Solids carryover, evidence of leakage into oroutof box etc:). D-box is structurally sound." PUMP CHAMBER: (locate on site plan) Pumps in.workingbrder.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Na (revised 11115195) ._:•- ..: :. _� a t _ _ � _!tom - _ �,,�'" - - SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM-- -PART C.- SYSTEM I.NFORMATION(contin.ried) -- = - Property-Addrass: 228 Old Homestead Dr.Marstn sills - - Owner: Glover:Box 333Marston NtIlts - -- - SOIL ABSORPTION SYSTEM (SAS) X (locate on site plan,if possible; excavation notr--quired,but may be approximated by non-intrusive methods) -if not determined to be present, explain: - Type: -_ ;_. leaching pits,number: 1,auo gallon leach p _ ' leaching chambers,number nfa leaching:galleri.es, number: �a ( leaching trenches,number,length:' leaching fields, number;dimensions:rye overflow cesspool, number:nta Comments:(note onditlon'of"soil,-signs of. c}fallure;'ieveI-of ponding,condition of`vegetation, etc.) The leach pit had 2'of water in it at the time of the in4kton It is structurally sound CESSPOOLS (locate on site plan) I Numb er and configuration' n1a _ Depth-top of liquid to inlet invert:nla Depth of solids Layer: n1a Depth of scum ayes nta Dimensions of cesspool:: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil, signs of hy&aulic failure, level of ponding,condition of vegetation,etc:) n1a PRIVY: (locate on site plan) Materials of construction: nia Dimensions: n1a Depth of solids:, nia Comments: (note condition of soil. signs of hydraulic failure, level of ponding,condition of:vegetation, etc.) PrivyComments (revised 11115195) SUBSURF E SEWAGE DISPOSAL SYSTEM INSRECTION FORM"" " - PART C SYSTEM IKFORMATION (continued) ""Property Address: � DMarsfu �ised — �•_ --- _ `_.:.-Owner: Clover.-Box 333 Marston Moll Date of inspection .e111198 SKETCH OF SENAGE DISPOSAL SYSTEM': include ties to at least two mar permanentreterences.landks or trenchmarks - - - _:.locate all wells within 100' _ A 376 - -G �CS7 b L3 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method'of determination or approximation: USGS Maps and Charts r ' (revised 1 tl15M5) .- _ r 9 V f (� TOWN OF BARNSTABLE LOCATION L4 J1 46W5-G-�Dc, SEWAGE # G_7r( VILLAGE MA(5160 ASSESSOR'S MAP 6z LOT 3`1 INSTALLER'S NAME G PHONE NO. T.3 . D"=fa LI 7`7( '3 j7 1�SEPTIC TANK CAPACITY O6 0 yA Q.LEACHING FACILITY:(type) (size) aaG sd„��a�s O , NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: d (,bf{� ' DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �' S l i7 ✓�1 ASSISSORS MAP N0: `� y `� THE COMMONWEALTH OFUMASSACHUSEETTS AARD PF .. ..................OF......... .. .: . (/`Ls .. . ............. Appiiratioaa for Bitipos ai arks Tonstrurti n Prrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at:A�­. %/f///�J /.................. ...................--.......-------.-./Z-* ........ .............N...:.... dCF-s�......................... ... Location-Ad ess �ps(oLot No. ............... .........._._ ......... ............. _.p. X_�rGX�.---.............................................--. W wnd es i�a.'•'r$� -;- d ' - ---_-----•--------- --f •°"`�1 Installer Address ����►► •� UType of Building Size Lot...ld,�_��.. __.Sq. feet Dwelling—No. of Bedrooms_____ Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria dOther fixtures ------------------------•------•-•--------------•-----•••••----------------•--•-•••••----•••-----------------------------•-•-•----•••.............._. W Design Flow................}$�-_.--.-_----------gallons per person per day. Total daily flow..._......�3 n...................gallons. WSeptic Tan_ —Liquid capacityAM. --gallons Length------- .... Width.... ....... Diameter________________ Depth................ x Disposal Trench—'\To..................... Width__ .� ....... Total Length......... j_... Total leaching area.._.. ._____........sq. ft. Seepage Pit No*---------/-______- Diameter.......�f__..__. Depth below inlet__..__..._.___. Total leaching area_. _sq. ft. Z Other Distribution box ( ) Dosing to ( l�) �[ �/J '~ Percolation Test Results Performed by.__.__. l .................. Date...... �.___U_S%........ a Test Fit No. 1....9------mmutes per inch Depth of Test Pit.................... Depth to ground water____-______.____---_-__ G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-________-_-.._.___--__. O ----- ---------------- � ------- ..... ` - y 9---------•---- Description of Soil-----V —?°J -------- � - = d - ' - x • -----•... ----------- --------- 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 i?:T_E 5 of the State Sanitary Code— e under • ned further agrees not to place th system 'n operation until a Certificate of Compliance has been 'ss y t d of h. jned... - ------------ ---•--- . --• ........................••------------Ovi Ye Application Approved B ............. PP PP Y •.............................. ................. ------- Date Application Disapproved for the following reasons-............................................... ----•---------------•-•----------•--•-------•------•--------•----•---•-----•-------------.................----.............--•---•------------------------------------------------------------------•--•- Date PermitNo. ....... Issued-....................................................... Date 1 Ni'KG....1-..... FEz..7.T. .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD ,q F LH]E7 A�jH T.... Apptiratiun for Disposal Works Tonstrnrtion Prrmit w " Application is hereby made for a Permit to Construct te-01)"'or Repair ( ) an Individual Sewage Disposal ''System at - -------------- _... A _.... :._...._..... 0 � Lot No..� 1 -.............._ .---- - Location- re ........... .:.mil'/. r --•-.-----•--------------------------------------- 11Ow er ._.1" /. -•------------------ ` -.-. Ins'a.ler Address �Qy� Type of Building Size Lot__/ff, ..----Sq. feet �-1 Dwelling—No. of Bedrooms___..................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _________________________- No. of persons............................ Showers ( ) —. Cafeteria ( ) Q' Other fixtures ............................... • - W Design Flow.............. , ....................gallons per person pex day. Total daily flow........ . .....................gallons. 1:4 Septic Tank—Liquid capacit/M.gallons Length......-K...... Width.._6........ Diameter________________ Depth................ W x Disposal Trench—No..................... Width ....... Total Length.................... Total leaching area --------sq. ft. Seepage Pit No......../--------- Diameter_---�.._...... Depth below inlet...-............. Total leaching area r�.,.eb_sq. ft. Z Other Distribution box ( ) Dosing tY4 ( ) '` ~' Percolation Test Results Performed by 6tl .................... Date_...7- 7_ .......... a Test Pit No. 1--- --------minutes per inch Depth of Test Pit.................... Depth to ground water......................... (s, Test Pit No. 2..._............minutes per inch Depth of Test Pit.................... Depth to ground water........................ J- - ------- Descriptionof Soil---- ------ ------ ----............. --------------•-•--•-•-•---•------•--------------------------- -...................----------- �----------------- x W ------------------------------------------------------------°---------�-�--=---�-------•--------I ............... 0 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 T? 'of the State Sanitary Code——he unde signed further agrees not to place t e syste in operation until a Certificate of Compliance has bee is edrby t e `rd of e�th. r -7 ' Signed / ....i ::....-----•......-- Dat . ApplicattoApproved By---... -�'-�._...••.................................................. " ` �•�4��� )dace Application Disapproved for the following reasons-------------•------------------------------------------•----......--------------------------------------....:_ .....................................................-•--------.----•------------------•-••---------•---'-----------------------------•--------•----..............................-- ----... Date Permit No`7��� .......:=:=-..I............ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F, HE T e �........G_J . ..--. Tntif iratr of TI-Implianrr THIS IS TO CERTIFY, That the Ino'ipid�al Sewage Disposal System constructed k r Repaired ( } by ------ —. ...1 � =�.��.� ' .................*--- In alter / has been installed in accordance with the provisions of Ti 1 i U j of The State Sanitary Code as described in the application for Disposal Works Construction Permit ...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................&. 0 ...` . ........................... Inspector.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTkI ...... ... .... O F. �/t .....t zt'....//...... ................................ .��..'''_`J, ��..... FEE..... ..—. ........---- Dispo.7l Works Tapv ptr uan anti# Permission is reby granted.........f'[,[.�...�`, �' . ccfv to Construct k7/ orRepair,( ) an I ividual Se ;age Dis sal S tem / +fir ' f Street _*�S, as shown on the application for Disposal Works Construction Permit ........ Dated.._.... ............ �( ..•.................................. Board of Health ----......_ DATE.--------�- ---1--Q-- ---"- FORM i255 HOBBS & WARREN. INC.. PUBLISHERS �►u c�►..� M1t5C 3" Dt oN� -Foe-- 3 mlo - zzo G-rev - 'A wea *: 330 X I UPETER O ° J��t-5/iil•i '-4•i�.a ISO. cJJ33: - C-AVac.%T`( 'I Sas F � 2.5 � S r - 375 so 5 F CA� 505rp 1•��+/5t 5� e�� � rt�t�� k�a`: -A Z 3t � • _ }- 4V i :�� 77.5 +G�- ��o� `� .. �. �� �o'a L• >-n���,�.fit _. 74.5 7-4,7 ;,� 75.1 l oo� T _ . .. t• lNV' �n�v ua� uaJ 'T:w.ttG,. �►.a�d LLlo6.5 ;� l OQ0�a!✓ PlT �-oT S �oMT~s'i't.,q-7 1�. 4wr _ w ���� w�sN6� � I...a«,-,o� r,�l��s��s r�,►.�s rrrb �zoPo9� �� �1✓M,\//a�ZwtzK �. Ac55oc,1 N�, F\( -T�-1A 7 TiA F- TC)U OU Si�OV/" I ►1�-z�.o�•-1 c.�M��Ys����-�t�i�- 5 ,�-:�', •,� � t� -J ���� �. P,l��,:_. I•�G, ---... del-lS-m5LF- }-,tJp 1,5 t for 1--oLa`�ci> N. UoT- 401 a- 2? — co �12p�o5F� �_C7 T � N �`/,�l-V..1 r`1�c N � I..O T"• �I �• �G�� \ lO M,J i=_„DTI ,A G-,eaV 6 � `Plz IOC%1.Xr'nd. ?06Ev GC2A,pF�. W }� o RICHAFID A. BAXTER- P1o. 24046