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TOw'N OF BARN-5TABLE
LqcA'I"ION SEWAGE #
Vi,>!.AGE �� L�,� ASSESSOR'S MAP & LOT Q
INSTALLER'S NAME&PHONE NO._
SEPTIC TANK CAPAC= 1
LEACHING FACILITY: (type) (size) j9 x
NO.OF BEDROOMS_
BUMDER OR OWNER
PERMITDA LE: COMPLIANCE DATE:
Separation Distance Between the: t
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Fee;.
Edge of Wetland and Leaching Facility(If any wetlands exist f
within 300 feet of leaching facility) �L Fc='-
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Commonwealth of Massachusetts
R W Title 5 Official Inspection Form
I^ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M ° 46 Peachtree Rd.
Property Address
i Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
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.
Important: A. General Information
When filling out 5�31
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return'
key. apewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S 14454
Telephone Number License Number
j
B. Certification
1 1 certify that I have personally inspected the sewage disposal system at this address and that thee.
information reported below is true, accurate and complete as of the time of the inspection The ihs'pection
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 tojSectioOr- .340Tof
Title 5 (310 CMR 15.000). The system: 4 it
® Passes ❑ Conditionally Passes ❑ F9111
CD
❑ Needs Further Evaluation by the Local Approving Authority
4/23/2009
Inspector's Signatur 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.
� qp
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
IW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is Marstons Mills 'Ma. 02648 4/23/2009'
required for
every 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:
The septic system is in proper working order at the present time.
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):
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.
46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
i
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:
i
❑ Cesspool or privy is within 50 feet of a surface water
i
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 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
�M 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 0264.8 4/23/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply 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 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 1/day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is,
required for Marstons Mills Ma. 02648 4/23/2009
every 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. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. Cityrrown 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?
® El information
the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 1,5.302(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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,distribution box and a 1000 gallon leaching
pit.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2007:100,000
g ( y g (gpd)): 2008:83,000
Detail:
2007:273 gpd. 2008:227gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/23/2009
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. Cityrrown 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: Capewide Enterprises,LLC.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured
Reason for pumping: Maintenance
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
IN Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron. ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appeat tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: 16"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 gallon
5"
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Water level was 50" below invert at time of
inspection.Stain line observed 25" below 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-09i08 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
�^M 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is
required for Marstons Mills Ma. 02648 4/23/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. Cityrrown State Zip Code Date of.Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 317
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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevetions.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 46 Peachtree Rd.
Property Address
Leo Speranza
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 4/23/2009
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
t; t
CommONNVEALTH OF jNLkSSACHUSETTS
-�
EXECUTBIE OFFICE OF ENVIRONI`4ENTAL AFFAIRS
DEPARTMENT OF ENVONMENTAL PROTECTION
IR
ONE RINTER STREET. BOSTON \L� 021US 16171 292•ai(t1�
TRUDY COS
Secre:arn
DAVID B. STP.::HS
ARGEO PAUL CELLUCCI Commiss::.ne:
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_.PART A
CERTIFICATION
1 1.0� Name of Owner j=ACN
Property Address: p
(µPc�Sor�sr��1iS Address of Owner: �•z--�•n
Date of Inspection:.
Name of Inspector(Please Print) r �S `U 5 of True 5(310 CMR 15.0001
I am a DEP approved system inspector pursuant [
Company Name: �/1
SR1 �y�• OLD L�-`1
Marring Address: ,
Telephone Number: S:00)
CERTIFlCATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
H
Conditionally Passes • c
_ Needs Further Evaluation QButhe Local Approving Authority
_ Fails
Date:
(nspectoi w
s Signare:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to ttre
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
6"
OA
46 PEOCH TREE RD., MARSTON MILLS
revised 9/2/98
pygc t of 11
Ci Prn+ted on It ey d Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
*ropertY.Address:
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes, no, or not determined(Y, N, or NO). Describe basis.of determination in all instances.,_Ifv"not determined explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health. . a
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
_obstruction is removed
distribution box is levelled or replaced - -
_ The system required pumping more than four times a year due to broken or obstructed pipels). The system will pass
Inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2ofIt
4
t
SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _
Conditions exist which require further evaluation by the Boar
d of Health in order to determine if fie system is failing to protect the
public health, safety and the environment. `
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 3 0 CMR 15.303(1)(b) THAT.THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt arsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WA SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AN SAFETY AND THE ENVIRONMENT.
_ The system has a septic tank and soil absorption system(SA and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system a the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system d the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system nd the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis f r eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the pr sence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
r;
1:1� .jz
. . ":f .. .
revised 9/2/98 Page 3of11
5
V �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
H CERTIFICATION_(corrtirwed) .
Property Addres
Owner:
Date of Inspection.
D. SYSTEM FAILS:
You must indicate eith r "Yes" or "No" to each of the following:
1 have determ ed that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination 1 identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes y—No .`' .
Backup sewage into facility or system component due to an overloaded or cogged SAS or cesspool.
_ Discharge ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS o,
cesspool.
Static liquid le I 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 1/2 day flaw.
_ Required pumping\ore than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspooil dr privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or�rivy is within a Zone I of a public well.
Any portion of a cesspool or ph is within 50 feet of a private water supply well.
well with
rivste water sup
ply e
• from a Y
_ Any portion of a cesspool or privy is less-than 100 feet but greeter than 50 teat f p PP
acceptable water quality analysis. 1t the well has been analyzed to be acceptable, attach copy of well water analysis for
•colitorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
n
You must indicate either "Yes" or "No" to each of the following:
\ 9
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or ore'of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking ater supply
the system is within 200 feet of a tributary to a surta\eddinking water supply
the system Is located in a nitrogen sensitive area(Inteellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in anee with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 s PliReioril yy
it
V i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
k _ Pumping information was provided by the owner, occupant, or Board of Health.
_ None.of the system components have been pumped for at least two weeks an&the system has been receiving trormal flow
rates- during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection. ..._ _ .. ..
J� As built plans have been obtained and examined. Note if they are not available with N;A=
The facility or dwelling was inspected for signs of sewage back-up. F
The system does not receive non sanitary or industrial waste flow. "' , r ', -_l_
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered. opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
)( The size-and location of the Soil Absorption System„on the site has been determined based on:
i A Existing information. For example. Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(I5.302(3)(b))
�1 The facility owner(and occupants,if different from owner) were provided with information on the propermaintenaaca-0f
7` SubSurface Disposal Systems.
revised 9/2/98 Page$of11
` AGE DISPOSAL SYSTEM- FORM.
SUBSURFACE SEW _
t a.;;.,4 PART C
SYSTEM'INFORMATION
'roperty Address: L G ?t1ta& Tat"
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: <-:-�Qg•p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):_ A-
,Laundry(separate system.) (yes or no): rU ; If yes, separate inspection required
Laundry system inspected es r no)
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage (gpd): I
Sump Pump(yes or no):
Last date of occupancy: t'1S PttLQk4- '
COMMERCIALfINDUSTRIAL:
Type of establishment:
Design flow: gpd I Based on 15.2031
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)=
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe) '
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of inforrtion:
yk tN1
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date Installed Of known)and source of information:
Sewage odors detected when arriving at the site:(yes or no) �
revised 9/2/98 Pegi6ofII
• y
w
SUBSURFACE SEWAGE DISPOSAL.SYSTEM LLINSPECTION FORM
PART-C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) v
Depth below grade:_
Material of construction: _cast iron_40 PVC_other (explain) _
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:V
(locate on site p an)
Depth below grader l2, ___. �_.._ -
Material of construction:4concrete_metal —Fiberglass Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions:
Sludge depth: +l Z(
Distance from top of sludge to bottom of outlet tee or baffle: ��,
Scum thickness: (tM u
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_
How dimensions were determined: `AAQCXAA+
3omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid levy- relation to outlet invert, structural integrity,
Sic
wk
in
evidence of leakage,etc.) a
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_,Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_;_
Distance from bottom of scum to bottom of outlet tee or baffle: _
Date of last pumping:
Comments:
(recommendation for pumping,condition of Inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/98 ' P age 7orn
r i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
,roperty Address: � (
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene_other(explain) v.
Dimensions:
Capacity: gallons
Design flow: gallons day
Alarm present
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: `) «
(locate on site plan)
h of liquid lev
el above outlet invert:
Dept q ��-1---�- q
Comments: - . .
(note if lev I and distribution i e al, a idence of solids carryover,
evidence of le age into or o of box etc.)
PUMP CHAMBER: -
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments: _ -.... ,` • . .. .. .,- _
(note condition of pump chamber.-condition of pumps and appurtenances,etc.! T w
. e
fl
revised 9/2/98 page eor11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Yoperty Address: tg'
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): S
(locate on site plan, if possible; excav Uon not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type.
leaching pits. number. (p&
leaching chambers, number:_
leaching galleries. number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(n condition of soil, signs of hydraulic failure, level of ponding, damp soil, conditio f ve etation, etc.) ` i� G
I
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
revised 9/2/98 Pece9of11
r 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) ,ry,F _
Iroperty Address:
)weer:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
u,
43
6
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwedl
roperty Address: e4act, ��rzksL
Owner:
Date of Inspection:
NRCS Report name b - — ---- - --
Soil Type_ ---------- ----
Typical depth to groundwater—___._ __
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep -- _
SITE EXAM Slope 0-0
Surface water p>L
Check Cellar 0"
Shallow wells Nf
Estimated Depth to Groundwater-�ZdFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
O's `J
R
i
revised 9/2/98 Page 11oru
ii
L O-C A T ION AGE PERMIT N0.
V I Lj`L A G E --= "�
0
INSTALLER'S NAME i ADDRESS
° LUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
ST�Z
G � +
2cfd n-.
� � I
N0.01... .1...: '" Fss..............................
THE COMMONWEALTH.OF MASSACHUSETTS
BO! a OF HEALTH
1o.u. ..�------ oF.......... .....:.. ewer ..(. --
Appliration for Disposal Works Tnnitrnrtion 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst t•
..1�/.� ................. ..... "fi ............................................
Locatiol.-Access_ t No.
_ Address
............................ .................................................................••----•..........................
Installer Address
Type of Building Size Lot2__1,124_j(�:__...Sq. feet
Dwelling—No. of Bedrooms........:...........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Buildin
a Other—Type g ............................'No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ----------------------------------------------------------
W Design Flow........... ................gallons per person peg dryy. Total daffy flaw.._..... ... .Q................�allons.
WSeptic Tank—Liquid capacity.l�Qgallons Length..�...Ci._._ Width_..�1_D.. Diameter................ DepthS .
x Disposal Trench—No..................... Width ,..----........_.. Total Length.....................Total leaching area--__-_----.-.-----sq. ft.
Seepage Pit No........Y......... Diameter.._-. .e.) Depth below inlet................ Total leaching area.Q:P...sq. ft.
Z Other Distribution box (�) tank ( )
'~ Percolation Test Results Performed! . . .--ice':-•---------------- Date �.. �----
Test Pit No. 1................minutes per inch Depth of Tes it........_......_._._ Depth to ground water..__.._..........'..___.
44 Test Pit No. 2.1--•--....... per inch Depth of Test Pit.................... Depth to ground water........................
IxV—z ....... ........................ �`�'- -- •---
O Description of So' - ..... �9� .- a:�C�L�. '' , �-'r /
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 TL I ME 5 of the State Sanita o e— e u signed furl s not to place the system in
operation until a Certificate of Compliance has een issued e and of heal
Signe ..e.. ......_ . ........................ . ......... ......-- . ..........................
Date
Application Approved By........ ................ -• •...... .
Date
Application Disapproved for the following reasons--------------------------------- ......................................................•-a.e..............
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•----•-••--------
Date
PermitNo......................................................... Issued_.......................................................
Date
r
led
No................. ' FEs. Q_.................
THE COMMONWEALTH OF MASSACHUSETTS
B0 Q_ OF HEALTH
I�Q I A•�t*.r�................O F...... .f�...--.....................
ApplirFation for Uhipoii al Works Tonstrareiinn ramit
Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal
.Systtt
--may_�•i_Rw._.,.. .......... ......... ......... In
................. .-....-__..._•___..._._. ..._ ....... ... .__...._.._.....-_.....-. ..............
r�Locatro A44s"s— ... ( -br Lot No.
• ^'?� �1"i-"T „�r,! �"t' ..._ft— ......(.......... .�........!"^.
W 06vner Address ,...,3
,rye_ �
...- ` .......... 5:�1.d"""..........................................}----___-__-_.-----._--•-•-•----_--_-----•---_- ........
Installer Address-
d Type of Building , Size Lo ....Sq. feet
Dwelling—No. of Bedrooms..__.,__:x .....................Expansion Attic Garbage Grinder ( )
Other—Type of Building .......................... No. of persons............................ Showers ( ) — Cafeteria ( )
P' Other tgures ....... f--"
W Design Flow.............. _.....________ gallons per person e� day. Total dai fiw__.... .............. �lons
WSeptic Tank—Liquid ca.pacityl4, - gallons Length_ . ___ Width.._*-1_Q_. Diameter______ _________ Deptl _....
Disposal Trench—No. ............... it_ :-..._...._ ._.. ' otal Le�igth.................... Total leaching area.___ ._ sq�ft.
Seepage Pit No..._..../ Diameter, � ... Depth below inlet_....# i .... Total leaching area.2 sglt
z Other Distribution box ( ) �.. tank
'-' Percolation Test Results Performed by _^}_1 . iF �..'............ ... Date..... . . _
Test Pit No. I................minutes per inch Depth of Tes'I it....._.............. Depth to ground water........................ 1,�
P P ln-
(T4 Test Pit No. 2__t............minutes per inch, Depth ofx Tes>APit ,"_: ,::,Depth to ground,water........................
O ., Description of So Q.'"�`h V',S e 3 �"�.--- - f.+.. •---- .� h j+c•
,. _ �
x ---- . `� ..-- . - -------• --------
w r '
U Nature of Repairs or Alterations—Answer,when applicable......... ......... ...................... ..................... a
*"
..................•------------•----•--•-•-•--.....-•--•--•-•--------... ...--•---•--... ..... .-
-•-•-==-•-•----•-•-----...----•-•..............................................
Agreement:
The undersigned agrees to install the aforedescribed,.Individual Sewage Disposal,System in accordance with
the provisions of.�TITLL 5 of thejState Sanita o"ile�=��ie iz j signed furth f es'not to.p'lace tli'e "syste min""'""' 't"
operation until a Certificate of Compliance has beeA'issued a and of heal
41
s z D t o
Application Approved By----- .r x £.. #�a6 + {
did
Date
Application Disapproved for the following reasons: =" ................... _
...........................•------------------•---------•--...--•------•------.=fix.-......-_.................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF .MASSACHUSETTS ++y., A #+
• Bg OF HEALTH
' .` .....................OF............................� � e< ..L ..............................
(9rdifirair of TompliFanrr ,
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( or RepairA
d ( )
by -nstall /� /�at..- uU__r e 1-i has been installed in accordance with the provisions of TIT" 5 of The State Sanitary C de as descrie
application for Disposal Works Construction Permit No.___._.___�- -------------------- dated.... t.....1..'i_--_-2-1._............
THE ISSUANCE OF ,THIS CERTIFICATE..SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUI4CTI9N SATISFACTORY.
DATE......... h 3 Inspector`.. /1.<. :::.:� .
THE COMMONWEALTH OF-MASSACHUSETTS
""""'1301AR•D,�OF HEALTH
7 7 7 7
C? *?`!-^'.............OF......................4............`.kg................................ �ry
No y1(,, FEE.....�v
Disposal rk� nn�firnr#irrn rruti�
Permission i reby granted............. .. -.TM
to Constr�( or epair. ) ndivi Sew Dispos ys
at No..... xd_ ...... .. (��" / .. ...�_'. 3t.'...l
Street /
as shown on the application for Disposal Works Construction Per o........ _ :. ted........ .
f
Board of.Health '.
DATE -----------------••---------------...--•-............-----•---••• '
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS at
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