HomeMy WebLinkAbout0070 RASPBERRY LANE - Health 70 Raspberry )�Marstons Mill
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills V Ma 02648 3-19-19
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.
Important:When filling out forms A. Inspector Information 51
4-
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
6
A (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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
Brett Hickey 3-19-19
..,Ome:2818.N.2011:.5:9-0atl V
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.
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T
Commonwealth of Massachusetts a
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
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: s
❑■ 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 system was in working order at the time of inspection.
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
f
i
Commonwealth of Massachusetts
,,p Title 5 Official Inspection Form
Ial Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. CRy/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(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
V
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
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
❑ a Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ED 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ O Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ a 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.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ Q 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 h g y g yste 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 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
u
,i Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
v
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
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"no"for each of the following for all inspections:
Yes No
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑I ❑ Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
El: El Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
R ❑ Was the site inspected for signs of break out?
El ❑ 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?
❑` O 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:
0 ❑ Existing information. For example, a plan at the Board of Health.
❑ ElDetermined 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)]
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I
Commonwealth of Massachusetts
�6 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r;
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 �
Number of bedrooms(design): Number of bedrooms(actual): 3
�
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/gpd
Description:
Number of current residents:
3
Does residence have a garbage grinder? ❑ Yes [j] No
Does residence have a water treatment unit? ❑ Yes 0 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 0 No
Seasonaluse? ❑ Yes [E No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
2018- 66,000gallons 2017- 56,000gallons
Sump pump? ❑ Yes ❑■ No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts J
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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? ❑ 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- last pumped summer 2012
Was system pumped as part of the inspection? ❑ Yes R No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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cep Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
v
Property Address
James Newton
Owner owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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:
5-23-97 per COC
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑cast iron H 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
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-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 70 Raspberry Lane
v— Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page.e. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
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
1
Dimensions: 500gallons
10if
Sludge depth:
26"
Distance from top of sludge to bottom of outlet tee or baffle
411
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
1211
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
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I
c� Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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
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: NA
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
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):
Oil
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�a) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes No*
Alarms in working order: ❑ Yes [E No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* 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:
(2)500 gallon chambers
Q leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name.of technology:
t5insp.doc•rev.R262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
it
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page.e. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System SAS Cont.
Comments(note condition of soil, signs of -lydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching was in passing condition. The leaching chambers had 6"of standing water when
viewed.
12. Cesspools (cesspool must be pumped as cart of inspection) (locate on site plan):
NA
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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 P Y rY
70 Raspberry Lane
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
V
Property Address
James Newton
Owner Owner's Name
information is .Marstons Mills Ma 02648 3-19-19
required for every
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 disposals stem, including ties to at least two permanent reference
9 Y 9
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑Q hand-sketch in the area below
❑ drawing attached separately
A REAR B
1
A1.32' B1-1TF'
A2.52' 132.25'
A3.58' 133.23'
i
t5insp.doc-rev.7/260018 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
J
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
L�
Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
page. C41rown State Zip Code Date of Inspection
D. System InformAtion (cont.)
15. Site Exam:
Check Slope
0 Surface water
IWE Check cellar
N Shallow wells
Estimated depth to high ground water: NoGW@14"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)
El Checked with local Board of Health -explain:
Information provided by The Board of Health
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A permit in the Board of Health records showed that ground water is >14'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Raspberry Lane
'V Property Address
James Newton
Owner Owner's Name
information is Marstons Mills Ma 02648 3-19-19
required for every
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
W 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
t5insp.doc•rev.7/26/2018 Title 5 Official!nspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE
LOCATION 76 [. y, SEWAGE # / 7-
VILLAGE /Q,�'�yyj Da2dLls ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. JE�
SEPTIC TANK CAPACITY 1��®
LEACHING FACILITY:(type) a _r6V 6,' 11 (`size) �%
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: vr- - �� ✓ 7
VARIANCE GRANTED: Yes No ✓
y
No. /� l �o J Y Fee SO
I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �f
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for Mtopozal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon Complete System ❑Individual Components
Location Address or Lot No. 70 A""V MY 1119 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel a //M SCE"&q
0
Installer's Name,Address,and Tel.No. &W Akm Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building R No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 770 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank anyo_ orlwy Type of S.A.S. i
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last 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 this Bo of 1361th.
Signed 4 Date -?7
Application Approved by Date 4>_ 1 Ci`7
Application Disapproved for the following reasons
Permit No. Date Issued
2 No. 1 / 1 D ``^-> Fee
-THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L
Yess
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pprication for Mizpooar *pztem Con!6truction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon(-<❑Complete System ❑Individual Components
Location Address or Lot No. Q ( 1 u Owner's Name,Address and Tel.No.
Assessor's Map/Parcel /� �SC��/y 4'i , r� (} 'A
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�7 40 Cis- th/j/ 7a6 /Hats ao��
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Zrinder( )
Other Type of Building A45. No. of Persons Showers( ) Cafeteria( )
Other Fixtures
i
Design Flow IV gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date. I
Title I
Size of Septic Tank_1 l90 (fxLG'�1 Type of S.A.S. L f WIM-/_ S'o
Description of Soil
i
I
i
Nature of Repairs or Alterations(Answer when applicable)
{
Date last 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 this Bo 'of alth.
Signed Date q7
Application Approved by Date c, f�
Application Disapproved for the following reasons
Permit No. �l '7 �h Date Issued
--------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by b, 4, t _
at V has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ! f dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date - �. '. a' Inspector " '
/"r`^� A---------------------------- —
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
1Wi9;po.zar 6pgtem Cong4ructiou Permit
Permission is hereby granted to Construct(' )Repair( )Upgrade(L-/)Abandon( )
System located at_ 7n
f
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.z
Date: F5/�7 L Approved by -
C
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
i, b -?qyC Z` , hereby certify that the application for disposal works
construction permit signed by me dated S-tZo"q- , concerning the
property located at Z02 9 y meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
j:ccrt
r
�50
s
,
d
,
SO
TOWN OF/B,A,RNSTABLE p
LOCATION 7�j SEWAGE / 7' l�j
VILLAGE / ��Tiylr�� 0�'11LLS ASSESSOR'S MAP & LOT QOc1�
INSTALLER'S NAME PHONE NO.R 45
SEPTIC TANK CAPACITY 1s��
LEACHING PACILITY:(type) IC.YJ G !/� �E �/�`size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: 17
DATE COMPLIANCE ISSUED: cS
VARIANCE GRANTED: Yes No ✓
ra
Comr' onwedth of Mcssoci`usetts John Grad
ExecutWe Office of Errdroru -antes Affeirs D.E.P. Title V ector
Departmeint of , A 025
Environmental Protection Te ) 564 81
Mq), �0 0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r+ 704vi7F 1 Igg,
PART A /gT%ti T ,
CERTIFICATION y�fPr�1F ~'
Property Address: 70 Rasberry Lane Marstons Mills Address of Owner: ti
Date of Inspection:4128197 (If different)
John MacSeveney
Name of Inspector:John Gracl
Company Name,Address and Telephone Number:
CERTIFICATION 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 This Inspection is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findinas are of how the system is
performing at the time of the Inspection.My inspection does
Needs Furl r E luation By the Local Approving Authority not Imply any warranty or quarantee of the longevtty of the
Fails`� septic system and any of Its components useful life.
Inspector's Signature: Date: 4129197
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. f
INSPECTION SUMMARY: V -(
Check A, B,C,or D: 3�
A] SYSTEM PASSES:
_I have not found any information which indicates 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 Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7o Rasberry Lane Marstons Mills
Owner: John MacSeveney
Date of Inspection:4128197
_ Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled or replaced
_The system required pumping more than four 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
obstruction 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 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A 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 septic tank 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 will 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 or surface waters due to an overloaded or clogged
cesspool.
x SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 70 Rasberry Lane Marston Mills
Owner: John MacSeveney
Date of Inspection:4128197
D) SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ 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 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 nitrogen sensitive area (interim Wellhead Protection Area (IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 70 Rasberry Lane Marston Mllls
Owner: John MacSeveney
Date of Inspection:4129197
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.
n1aAs built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs 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 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.
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.
S
(revised 11/15195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7o Rasberry Lane Marston Mills
Owner: John MacSeveney
Date of Inspection:4128197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: o gallons
Number of bedrooms: 4
Number of current residents: ll
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n1a
Last date of occupancy: 1 month ago
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:ll gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last year.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:o gallons
Reason for pumping: n1a
TYPE OF SYSTEM
Septic tank/distribution box/soil absorptions system
X Single cesspool
X Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source_information:
25 years
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7o Rasberry Lane Marston Mills
Owner: John MacSeveney
Date of Inspection:4129197
SEPTIC TANK:_
(locate on site plan)
Depth below grade: n1a
Material of construction:x concreate_metal_FRP_other(explain)
Dimensions: n1a
Sludge depth:n1a
Distance from top of sludge to bottom of outlet tee or baffle: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance form bottom of scum to bottom of outlet tee or baffle:n1a
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.)
n1a
GREASE TRAP:_
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
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)
G
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Rasberry Lane Marstons Mills
Owner: John Macseveney
Date of Inspection:4128197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: Na
Capacity: n1a gallons
Design flow: Na gallons/day
Alarm level: Na
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Na
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Rasberry Lane Marston Mills
Owner: John MacSeveney
Date of Inspection:4128197
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type: �I
leaching pits,number: rda
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number,length: n1a
leaching fields,number, dimensions:n1a
overflow cesspool,number:6'x6'
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Cesspools are past the effective depth of leaching System is In hydraulic failure.
CESSPOOLS:X
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: level
Depth of solids layer: 14"
Depth of scum layer: 1'
Dimensions of cesspool: 5'x6'
Materials of construction: block
Indication of groundwater: none
inflow(cesspool must be pumped as part of inspection)
Na
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
System is in hydraulic failure.
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
n1a
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 RasberyLane Marstons Mills
Owner: JohnMacSeveney
Date of Inspection:41211197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
O A
09
VA
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9