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Commonwealth of Massachusetts 0�3 -001 -OOLY
p Title 5 Official Inspection Form
? I Subsurface Sewage Disposal System Form Not for Voluntary Assessmentsrri
248 Olde Homestead Dr � +
Property Address
Peter Vangel ';
Owner Owner's Name -r
information is
required for every Marstons Mills MA 02648 9-14-18 -
page. City/Town State Zip Code Date of Inspection t
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. Inspector Information
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Boz 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] am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);l have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1.' ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
9-14-18
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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving-authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
rl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18 r
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and'all of 4 and 6.
1) 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.
2) System Conditionally Passes:'
❑ One or more system components as described in the "ConditionalPass" 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 exMtration 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 El ' ❑ ND (Explain below):
- F
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>" 248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
9 Title 5 official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
ray Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� K1r
f" 248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is Marstons Mills MA 02648 9-14-18
required for ever
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet 'invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow ' '
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 .
Commonwealth of Massachusetts
I�l•
Title 5 Official Inspection Form
µ„
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) = `
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"'or"rio"for each of the following for all inspections:
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?
f' ® ❑ Wasthe 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 theBoard 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)]
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c " Commonwealth of Massachusetts
is p Title 5 Official Inspection Form
! i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required fcr every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information ,
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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: 9-2018Date
t5insp.doc•rev.7/26/2018 .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
a
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Olde Homestead Dr ;
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? r ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
` Other(describe below):
3. Pumping Records:
Source of information: Owner--pumped 2016
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
r How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc-rev.7/2 612 01 8' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not forVoluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 20"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.
t5insp.doc•rev.7/2 612 01 8. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
r� ,w; Title 5 Official, Inspection Form
10l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
}� M�
248 Olde Homestead Dr
.=.r-
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 14"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: 4 1
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
i k Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
1�'
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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: 0 1 ,
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
I
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection' ' Form
hl Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town ` State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
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
9. 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.
i
,
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
pit Title 5 Official Inspection Form
C�i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
>' 248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan): t
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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
T e/name of technology:
9Y:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
3/ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Olde Homestead Dr
._r
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.) y .
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Infiltrator leach field in good working order and holding 2" of water with no sign of back-up.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration I
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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev,7/26/2018 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts i,
r� Title 5 Official Inspection Form
R'f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for even Marstons Mills MA 02648 9-14-18.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
t t
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2E/2018• -- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
pi Title 5 Official. Inspection . Form
1, Subsurface Sewage Disposal System Form _Not for Voluntary Assessments -
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
a s , .rr�rvrsr f.
d
Aof
41
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
ra 0.7 Title 5 Official Inspection Form
HI Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth o high ground water: 12'+
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 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.712e/2018• - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Olde Homestead Dr
Property Address
Peter Vangel
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-14-18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed '
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
N J
' No. —G5 Fee 4es
THE COMMONWEALTH OF MASSACHUSETTS Entered in co
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for nigpozal *potem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade/Abandon( ) ❑Complete System 2f Individual Components
Location Address or Lot No. al�WOwner's Name,Address and Tel.No.
Assessor's Map/Parcel
InstallWs blame,Address,and Tel.No. Designer's Name,Address and Tel.No.
771-���9
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder
Other Type of Building �'! No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �'�!� gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank eel Type of S.A.S. Z4e XZ -11",,11*12G,9S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date las inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by is B ar f H Ith
Signed Date
Application Approved by Date
Application Disapproved for tW followQg reasons
Permit No. Date Issued
_ .
No. Fee' _
l Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS t f
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, M�ASSACHUSETTS ^'`-� __.
Zippiication for Migaar bpotem Con0truction Permit
Application for a Permit to Construct Repair Upgrade Abandon El Complete System Z Individual Components
PP� ( ) P ( )UPg ( ) ( ) P Y P
Location Address or Lot No. �7/1!� O� ey f�®� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Marne,Address,and Tel.No. Designer's Name,Address and Tel.No.
77/��3f9
Type of Building: ? /
Dwelling No.of Bedrooms ✓ Lot Size sq. ft. Garbage Grinder('
Other Type of Building /f�rl�C� No. of Persons Showers( ) Cafeteria( )
{ Other Fixtures
Design Flow /D' gallons per day. Calculated daily flower gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ! XX/STD AW A Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
.f
+- ,
r
Date last inspected:
,d
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system�in operation until a Certifi-
cate of Compliance has been issued b B f H•alt
Signed Date
Application Approved by r-' Date
Application Disapproved for e follow ng reasons
f
Permit No. Y7 - S J Date Issued
THE COMMONWEALTH OF MASSACHUSETTS OZ1 j-2� Dl GVq y
t BARNSTABLE, MASSACHUSETTS
E. .
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sew ge Disposal System Constructed( )Repaired ( )Upgraded(
Abandoned( )b ��®� � D ✓�
at ,7 y al�i7 Ilelovel-SIX14WOF a/, has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. .9, ;'- ,.1 Y J. dated
Installer Designer Aa A
The issuance of this permit 11 of be ons ed as a guarantee that the function as designed��
Date Inspector �� l v
—--————————————————————————----——————————
G
No. 1 7— J f 2 -. Fee 570
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
xigpozal *pgtem Conwt�tion Permit
Permission is hereby grante to Constructs, ) epair( )Up gra e( Abandon
System located at Z O�DGOrll ,Sj�°Q, D�
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: j Q — f " 27 Approved by � .
S
.ti
�IJ f
�� S
ov
0
I
6 LOL
NOTICE: This Fo,rm Is To Be Used For the Repair. Of Failed
Septic Systems Only.
CERTTFIC aTION OF SKETCH.kND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PE [IT (N-VTMOUT DESIGNED PLANS)
`/--ebV C:'—. t�'iai -he arriicarion ibr :1SiGs31 wv^iis
�QIlSv"L1CLii n �e1Z?11I ignzC j rl e ?aIL'Q ����< 7 7 . �Oncz'ii "=.a
7ICC�r.'i ,CC3Iz :I 615 ®/(/�
Y - -- --
:�r
HONNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER INS TOWN OF BARNST.aBLE tiZ'yBER
[.attach a sketch plan of the proposed system. Also if to licensed installer posesses a cerrified plot piar..
this plan should be submitted].
j
'l TOWN OF BARNSTABLE
LOCATION: Z7 ®/��J4�i��5a� D/'. SEWAGE # 97:S—SZ
VII.LAGE /�L_y/s /1 �Ii'//y ASSESSOR'S MAP & LOT J /�
INSTALLER'S NAME&PHONE NO. �6'1,f4!p J 1 Oey ` 7
SEPTIC TANK CAPACITY 1000 L '
! LEACHING.FACILnY: (type) 2-4J11 '
,.�(size) /O
I NO.OF BEDROOMS
BUILDER OR
PERMTTDATE: Al"/ Q7 COMPLIANCE DATE: �7
' Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet`
Private Water Supply Well and LeachingFacility ty (If any wells exist
on site or within 200 feet of leaching facility) Feet.
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) -41114 Feet
Furnished by
�q,
N5 e 0 3'F
.
P
DOL
TOWN OF BARNSTABLE
r�
LOCATION o��,f � �-r' SEWAGE #
VILLAGE 2a"& && ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r
of
i
I ` -
i
r TOWN OF BARNSTABLE
1.�
LOCATION 7-7 ®���/�� t�5 �� D�� SEWAGE # 97 53 2-
VILLAGE, &ZZI 4 "eII'//� ASSESSOR'S MAP &`1:OT 0J--
INSTALLER'S NAME&PHONE NO. 7
SEPTIC TANK CAPACITY. I, o 0 p
LEACHING FACILITY: (type) ftor I �y� (size) Id,< 30'>cz
NO.OF BEDROOMS ,f
BUILDER OR OWNEjkh
����
PERMITDATE: AP/ 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist I/
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist J //
within 300 feet of leaching facility) L/� Feet
Furnished by
Pall�V
N5 3,'
O
��vL
TOWN OF BARNSTABLE
LOCATION 1_6I � �j ���e �tl�f�0�� �`,�� SEWAGE #
�stl3-l�e� tao
VILLAGE Vv-ovCS0hs �'��S ASSESSOR'S MAP 6i LOT e I
INSTALLER'S NAME Sk PHONE NO. '� • �` 'S�d�, �� C—� ���
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) L-eenok (size) I C)(A) 1 q(IOHs
0 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER �" Y S� �`�` 'kt Co
DATE PERMIT ISSUED: o 4 . 1,6 (a(Ka
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No 1-
t J
i
V7
L-64
ASOUSSOR3 MAP NO: . . - / P ` ; "
PARCEL NO.: .
----- .---- ..76i40..__
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Utz c 0yV............O F.......,( I'L0.144UP.6
Applira#iun for Disposal lVark.6 (fun arn.rtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at.
- ....
Location-Address �,�" Lot No.
--------------------•..----------...--•--•-•--•----- 1.l�1/�0 t'1.11....._t ...............................................
Owner Address
1.�Ae2Af�!_-_1 ...
Installer Address
UType of Building Size Lot.....�-�Y... fa_c -----Sq. feet
Dwelling—No. of Bedrooms......J,6 ---Expansion Attic ( ) Garbage Grinder ( }
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -----------------------------••••-
W Design Flow............. ........................gallons per person per day. Total daily I flow-----__._.330.......................gallons.
1:4 Septic Tank—Liquid*capacityl jO.gallons Length......V...... Width......6....... Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length................. Total leaching area....................sq. ft.
Seepage Pit No..........(.......... Diameter-------- ........ Depth below inlet..........L...... Total leaching area....c20.Q...sq. ft
Z Other Distribution box ( ) Dosing tank (
Percolation Test Results Performed by....W W
�:_.._. i(_&e�........................ Date...... l /$6._....__....
a
Test Pit No. 1.....4� ....._minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ---•••••-•••-----------------•-••-••--•-•-••-•-••••••-•---...._...•---••......_.....-------------•--.........................................................
Description of Soil 0 TQ --�----."tj2� 4 ------------------------------------------•----....--------------------------•-------------
t i -
U1, M
UW ••--•-•-•--•------ ---------•------•---•------------------------ .-----•-----...--------......------------------------------------------------------------------------------.
Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------_.....................
Agreement
The undersigned agrees to install the aforedescrib d Individu Sewage Disposal System in accordance with
P Y
the provisions of iT:12 5 of the State Sanitary Cod The and signed further agrees not to place the sys inin
operation until a Certificate of Compliance has been ed t oard of health.
77/
Signed.............. .. ...... . •.••..............................
Application Approved BY.............................=......•..... ......•q-::.......................•-•----- ----���#---�--------
Date
Application Disapproved for the following reasons------------------------------•..----•--•----------------------•-•----------------------••--•......----••-•----
.........................••--•------•------•----...----------...-•--------------•----•-----•--....------.-•••-•-•--•-•-••••----•-•-•----•-•-•---•-•••••••••••--•••••----•------•--•••-•---••---••-•-•---
Permit No........ ` •. ±-� Date
- -_--- Issued-------------------------------------------------------
i
Date
............... Fmcl..7.5A ..-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........Ta -------I.......OF.....jV.Z1_0hq..k6
Appfiration for Dispaiial Workii Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System,at:
a.. ...........P/4L.-ILD.&A.4/.... -------------------------------------------------------------
Location-Address r Lot No.
.............
ZI y U/-,./..................................................... . . .. ...... --------------------------------------
Owner Address.. . ........
.......P. Hit .................................................. ........................................................
Instafler Address
Type of Building Size Lot...19_,,.'qb.3......Sq. feet
U
Dwelling No. of Bedrooms.._.. .....Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons...._....................... Showers Cafeteria ( )
QI
Other fixtures ---------------- ............................................ .......................... .............................................................
< Design Flow..........S.5..........................gallons per person per day. Total daily flow..........3je).......................gallons.
9 Septic Tank—Liquid capacity/4)(90..gallons Length-___-F........ Width....6-------- Diameter_______________ Depth................
Disposal Trench—No..................... Width.................... Total Length...............I.... Total leaching area-...................sq. ft.
Seepage Pit No........I----------- Diameter......2.......... Depth below inlet.........42........ Total leaching area..d0.0....sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by W�r W-AA&M.-Ck........................... Date....V l:.. .............
'Test Pit No. I....o.L........minutesperinch Depth of Test Pit.................... Depth to ground water------------------------
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..____._.....___......__
P4 .............................................................................................................................................................
-
0 Description of Soil......... .O..:i 3..I......xco......1......WILL04VZ..........................................................................................
U .......................................... ..................................................................................................
------------------------------------------------------ --------/V0..t/_A�..............................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.___...........................................................................................
............................................... ..................................................................................... ......................................................
Agreement:
The undersigned agrees to install the afo-,edescribed Individ l Sewage Disposal System in accordance with
of the State Sanitary gCo�d The gned
e ' --i
the provisions of T-1 The un rsigned further agrees not to place the sys em in
f
operation until a Certificate of Compliance has ben ed t oard of health.
Sig.ne .... .. . .. ............................... ... ...... ...............
. ......... ...................
Application Approved By............................ ......... ........ 04�
4 Date
Application Disapproved for the following reasons:.................................................................................. .....................
.........................................................................................................................................................................................................
Date
Permit No.._..-- .....—TES Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
It—..........I.......OF....13.eV. .........................................
ToWrtifiratr of TOMpliaurr
THIS-IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired
......................... .........................................................................................................................
Installer
. .........
t .A�4.ec
at..... .......0/2L........ .0,2.d..... ...................................
has been installed in accordance with the provisions of TITIE'_ i The State Sanitary Code d s ed in the
0
ion for Disposal Works Construction Permit No...... 7ES. ...... _�te� _�T
application d ..........
S H
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A/A YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................&..n... -..�456 .................... Inspector..................�k.....y................................................
Pm COMMONWEALTH OF.MASSACHUSETTS
BOARD OF HEALTH
..............v3 ............ ............0 F....
X_'�25 -71.... .......................................... FE2 .......0...........
Disposal VorWp %Tomitrurtion "rrmft
V
Permission is hereby granted---- ------01.�.kb r...........................................................................................
to Construct (),/A or Repair an Individuaj Sewage jisposal System
'.).'f.otl�a A ......... .......i-------------- Ilk at No....JL0.t ....0. 1.4)_U ----- -----
Street
,,& -7 Date as shown on the application for Disposal Works Construction Permit ----
............ - ------- -- ---:�OA .........
............................ ...........................
Board of Health
DATE..0jd.0kQ--. t vm6.....................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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