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Home My WebLink About0139 REGENCY DRIVE - Health 139 REGENCY DRIVE, M. MILLS -- - - - A= 063 073 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I :F 139 Regency Drive ► Property Address ' David Gould ;. Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 " page. City/Town State Zip Code Date of Inspection ri 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 6'1 :* 3 �a on the computer, use only the tab Patrick Rutledge key to move your Name of Inspector cursor-do not Title Five Specialists use the return Company Name key. Taftst Co A �y Company Address Dorchester MA 02125 Cityrrown State Zip Code 5082374628 S114198 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 — 6/29/2019 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. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18 f s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owners Name information is Marstons Mills MA 02648 6/28/2019 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 olds'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.7/2R=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Citylrown 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 broker.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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Citylrown 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. ElThe system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The se system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or Y P more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Cityfrown 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 a//inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank r material of construction inspected for the condition of the baffles o tees, , p dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doo•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if.available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap,present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ 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: Within two years according to owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 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 ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100' feet Comments(on condition of joints, venting, evidence of leakage, etc.): No leakage noted t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tee in good condition, No signs of leakage, Pumping not needed at time of inspection t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is Marstons Mills MA 02648 6/28/2019 required for every page. Cityrrown 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): 0,r 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.): Box is level and equal, No carryover, No evidence of leakage t5insp.doc-rev.726=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is Marstons Mills MA 02648 6/28/2019 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 ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump and alarm in working order. *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: v rflow cesspool El o enumber: ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of hydraulic failure, no ponding, no unusual vegitation 12. 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 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name information is required for every Marstons Mills MA 02648 6/28/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately l ank .� ,4_ Porn®T-nk 4 a 2S 'r. - 39, D boy C-e � Qr �Y, ^1C 6 t 13q A . a 0 t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive Property Address David Gould Owner Owner's Name required for Is Marstons Mills MA 02648 6/28/2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >120" Estimated depth to high ground water: 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: Test hole on asbuilt ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole on asbuilt 2007 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 ITitle 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Regency Drive ir.". Property Address David Gould Owner Owner's Name information is Marstons Mills MA 02648 6/28/2019 required for every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.R260018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 4 COMMONWEALTH OF NJ-ASS?►CHt SETTS EXECUTIVE OFFICE OF E?�NIRONNIENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO*TECTIO_' ONE WINTER STREET. BOSTON. AtA 02106 bl'-:S=•E:OG 1 4 �4,24, 1 F %1LL1A%1 F.SILD .j ��^� TRl 1 CG?- ly ARGEO P. Gt CE� LLl'CCJ. .. . _.. .-•: . .. . . _ opTs9 Ls.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM e�' y�o�mtaissiarrc (''� 1)z ®b� PART A CERTIFICATION Property Address; %3°1 STbr•r� M DES Address of Owner: (j3 s 1 Vat j,q V-W.,t, Date of Inspection: 2skC, 'qf different) 16 Gr Name of Inspector. 1 C ro I am a DEP ap roL.ved system inspector pursuant to Section 13.340 of Title S (310 CMR 1 00 ��0 � Company Name& a op-, 'a jag p�n.,.+ we e - 4_ l �Z6 LA Mailing Address: 'Pe) ./3opc P-3;'? �i H A!C11,0�- H 2 4.47 . Telephone Number. rSG C�c. �— /46 o CERTIFICAT1O% STATEME%%T I certif that I have pe•sonall mspeeed the sewage d:s*osal system a: this address and that the iniar ation revarted be:o% is true. accurate and comolem as of the time of inspec:oo-�. The inspec:;wi was pe-formed base=.on my training and experience in the proper iunrzicn and maintenance o�on-site sewage disposa; systems.. The wimm: Pastes - _ Conctt.e^ai;% Passes %eecs Funhe- Eya!uatlam By the Local Approving Authcrtt% Fa Inspector's Signature: Date: 3 T;;e Syste-r Insze=- sha" subrnit a copy of this inspecttan reccn to the Aporaving Authority within thi m. (30, days of completing this inspection. It the syste-n is a shared system o- ha; a de:.gn flow of 10.000 gx or greater, the inspe:or and the systeT. owner sFzll submit the resort to the aaoroartate regional os;ce of the De:anment of Enyircnmertta' Frotecion. The oriSma! .should be sent to the system owne- and copes :-•t:to the buyer, if applicable. and the aparaving authority INSPECTIO` SUMMARY: Check A, E, C, or D AI SYSTEM PASSES. I have not found any information which indicates that the system violates any of the failure criteria as define? in 310 C.MR 13.303. Any failure criteria not evaluated are indicated below. COMMENITS: '�FAPjze + is NU Ste-%"oF bXCAL yp tr}T Tkwu_of- Itc) SO&&J eaL Sysy", Q4ssts `ou S Wt_jLkC4._ Yh%'i s �gba�ool�IMr1tR.�i� aMd. �,�� Nc�d vQ��'►��^'"1 �N��Tv , 81 SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The systern, upor. completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'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 (attachedi indicating that the tank was installed within twenty (201 years prior to the date of the inspection: c' the septic tank, whether or not meal,.is cracked, structurally unsound, shows substantial infiltration or exfiltratton, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank w approved by the Board of health. IrOv:114114 WWII) 1eg0•1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' t CERTIFICATION (continued) Property Addr.`ss: Owner: - Date of Inspection: 61 SYSTEM CONDITIONALLY PASSES tcontinuild Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe:si or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Healthi. Describe observations: 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 pipe(st.:The system will pass tnsceaion if twith approval of the Board of Health): broken pipelss are replaced obstructior is removed C3 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the i%•stem is failing to proteci the public health. safe:%•and the environment. - . . . 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCrIONIN-G IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. Cesspool or prr%1 is within 50 fee, of a surface water Cesspool or prr%N- is w ithin 50 feee, of a bordering vegetated wetland or a salt marsh. T) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER.vtl-SES THAT THE SYSTEM IS FUNCTIONING IN A MAN'�ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY ANO THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS, and the SAS is within 100 feet to a surface water supply or tributary to a surface water supoly. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supaw well. _ The syste•n has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption syste-n and the SAS is less thar. 100 fee! but 50 few_! or more from a private water suppl% well. uniess a we!I water analysis for coliform bacteria and volatile organic compounds indicates the the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid): 3) . OTHER (swi••d 0�:75/�') Page 2 of 10 fr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 'Property Address: � Y3G Owner:�Cyv Date of Inspection: .•a� 1�ca Check if the following have been done: You must indicate either "Yes" or "No"as to each of the following: Yes NC 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 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 pan of this inspection As built plans have been oo;ained and examined. Note if they are not available with NIA. _ The fac:11-% or d%%eking was inspected for signs o;sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site %%as inspected for signs of breakout. x _ All s\�terr co nponent_. excluding the Sod .Absorption System, have been located on the site. The septic tans: manholes Nere uncovered, opened. and the interior of the septic tank was inspected for condition of bafiies or tees. materiai. o;construction. dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption Svstem on the site has been determined based on. The iacdwn o%%ne• •,ano occupants. if dirteren: trom owneri were provided with iniormation on the proper maintenance of Sub-Suriace Disposal Svstem. Existing iniormation. Ex Plan at B.O.H. _ De;erm-ed in the meld ni an% of the failure criteria related to Part C is at issue, approximation of distance is unaccep:aoie [15 302+3):b1 (revised 04/25/57i page 4 of 10 i� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,tit PART A CERTIFICATION (continued) Properh Addross. Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following - I have determined that the system violates one or more of the following failure criteria a< defined in 310 CMR 15.303. The oasis for this determination is identified below.. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into 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 SAS or cesspool. Stanc hcu:d level in the distribution bo> above outlet invert due to an overloaded or clogged SA5 or cesspool. L:eu:d depth in cesspool is less than 6" below invert or available volume is less than,1/2 day floe. Recuired p-imping more than 4 times in the last year NOT due to clogged or obstructer pipes . Number o�times pumped An• portion of the Soil Aosorpuon Svstem, cesspool or privy- is below the high.groundwwate• elevation An,, por :on of a cesspool or privy ,s within 100 feet of a surface water supply or tributary to a surface water supply. Any por::on of a cesspoo! or pri%1• is w rth:n a Zone I of a public well. Am pc^ic-• of a cesspool or privy is within 50 feet of a private water supply well An% por.,or. o' a cesspool or pr:%y is less than 100 feet but greater than 50 feer from a private water supply well with no acceo;abie Ovate, qualm analysis. If the well has been analyzed to be acceptable. acach cope of well water analysts for cohiorm baser:a volatile organic fompounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: 1 ou must indicate either "Yes' or "No" as to each of the following. The following c•ae,la aop;, to large systems in addition to the criteria above: The s•stem se ves a facilm with a design flow of 10,000 gpd or greater (large System; and the s•stem is a significant threat to public hea!th and safety and the environment because one or more of the following conditions exist. 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) 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. (rwixed 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.�,t PART C SYSTEM INFORMATION- Propert% Address: \Y, Owner: yLw�� 1 `� Date of Ihspection: 31Z3 c1b FLOW CONDITIONS RESIDENTIAL: Design floes 330 ¢p.d../bedroom for S.q�S Number of bedrooms Q? Number o**current residents C> Garbage g,: der (yes or no.---ND Laundry co.—ected to system (yes or nog l�J Seasonal use Ives or no-,— Water meter readings, if available (last two :2 vear usaee (gpd) Sump Pump (ves or no) Lai: date o`occupanC% v' u COMMERC;4L'INDUSTRIAL• Type or establishment Design fio%% ¢ahons/aa\ Crease trap present tve5 or no_ Industria! Taste Holding Tani; present. eves or no ,on•sanrtan v%aste discnargec to the T!tie 3 sysem. iyes or no_ \\ater meter readings if availabie Last pate 0: a C- ;,a^c, OTHER: .Z)escribe Last pate of occupa-ic. GENERAL INFORMATION PUMPING RECORDS and source of informatior. IJJ System pumped as par, of inspection. Ives or no.-120 If yes, volume pumped ¢allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Singe cesspool Overflow cesspool Prn-)- Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of a'I components, date installed (if known) and source of information: y yU U It..0 Sewage odors detected when arriving,at the Site. (ves or no)Ala, (revised 04/25/91) Page 5 of 10 SUBSURFACE SE��AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE!-1 INFORMATION (continued) Property Address: Owner: Date of Inspection: / BUILDING SEWER: (locate on site plant / i Depth below grade ' Material of construction. _cast iron _40 P�'C _ other (explain( Distance from private water supply well or suction li-t Diameter ' Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK:_ (locate on site plan Depth below grade Material of construLmo _concre:e _me:a _Fioerglas` _Polyethylene _och/texplain If tank is metal. Its: age _ Is age cor.:;rmec 0% Ce^.:fica:e of Compttance _Oes.;No Dimenstor.s Sludge depth Dtsiance from top o: siudee to bortorn of outie: tee o, ba le Scum thickness t Distance from top of scum to top 0-. 0uile: tee or bade Distance iron bono-, of scum to bo-oT o� outie: tee cr bar'-e Move dimensions Here determinec Comments ' ructural .. r 'i r , inlet arc outlet tees or idanles. depth of liquid level to reiatton to outlet invert, st trecommendat�on icr pumping. ro ct o o / integrity, evidence of leakage. e;c.t 1 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 t•,let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural mtegrtty, evidence of leakage. etc.; (re,ised 04/2SA Page 6 of 1C f I P , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.�t / PART C - 1/ SYSTEM INFORMATION (continued) , Propert% Address: ON ner: Date of Inspection: TIGHT OR HOLDING TANK: -Tank must be pumped prior to, or at time, of inspect ion t (locate on site plan, Depth below grade. Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(e%plain) Dimensions: Capaciry gallons Design flow gallons"da, Alarm level A�arrn in �%orking order_ Yes: No Date of previous pu.,nping Comments (condition of Inlet tee. condmor. o* a!a,m and float switches. etc.l i DISTRIBUTION BOX:_ (locate on site plan Dnzt i o; licuid le%e' aoo�e oune: in.e- Comme^ts mote : leve! and d!stribu:,or is ecua' evide-ce of solids carryover, evidence of leakage into or out of box, etc.l PUMP CHAMBER: (locate on site plan_ Pumps in working order: (Yes or No A:arms in working order (lees or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rw:sed 04/29197) Page 7 of 10 ' 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Jr SYSTEM INFORMATION (continued) Property Addr-ss: l✓ 1 'W'I Owner: V4&t*jo Date of Inspection: 3 3`�b SOIL ABSORPTION SYSTEM (SAS):_ (locate on s(te_plan, if possible, exca%ation not required. but may be approximated by non-intrusive methods: If not determined to be present, explain: Type: leaching pus. number._ leaching chambers, number:_ leaching galleries, number: leaching trenches. number,length: leaching fields, number, d.mensions overflow cesspool, number Alternative system Name of Techno(og% Comments. (note condition of soil.s!gr.s of hydraulic failure, levei of ponding. condition of vegetation, etc., CESSPOOLS: c (locate on site pl r. Numbef and coniigura:10^ oC P�1vr�x� Depth-top of liquid to inlet Inver, i i'�� '� b Depth of solids lave, d' l" 1* Depth of scum layer "l' Dimensions of cesspool GA.11PiA Materials of construaior Ccr--te.CLTL Indication of groundwate• tJ inflow (cesspool must oe pumpeC as par, of inspection ••. Comments: ( to condition of soil, signs of hydraulic failure, level of ondi c dition of vegetation, etc.) - - ,� vaFrr:Z SvLCv,uQ i.b•;sL. tS V�cc.,.-�F� T- Ar �1 eQ Lis Ru- O1` . ca"Poo 1 t)..9r11 Nt�,c)• vPk��Nq 4NF-t31U�. PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, levei of ponding, condition of vegetation, etc.) (r.vi..d 04/25/9') P.y6 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued Propert% A'dd/,ress:,L3� E.Lgt►x-� Owner: '�/C.1/KIQ(a;�' Date of In,pection: 3)2ISlct�, SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reverences landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) R 3c1 d C (revised 04'25/5-) Page P of 10 i Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Proper 'A�ddres-- Owner: Date of Inspection: 31Z31�j� t Depth to Groundwater 7Q Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abuning property. obsenation hole, basement sump etc.) Determine it from local conditions Cneck %%,in Iota' Soard o• nev- Check FE.-,1A Macs Check pumping records Check local e*cavato,s installe•s L se 5:_ Data • Des r ribe in poi, o�%- -01c- ro••• o:. es:abl-her, the nth Groundwater Elevation. (Must be completed lzw.a�d 0�.'25'9' Page 10 of 10 BQt,tle• Number : 714001 Date : 03/04/98 R O� B`9�ii, BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE O BARNSTABLE,MASSACHUSETTS 02630 PHONE:362-2511 111A 5 S LAB 337 Collector: H. HILLER Client : HILLER. H. Mailing P 0 BOX 250 Affiliation : Address : CEN.TERVILLE , MA 02632 ply : Type of Sups Telephone: 778-1472 Well Depth: Sample Location: 139 REGENCY DRIVE Date of Collection : 02/25/98 Town : MARSTONS MILLS Date of Analysis : 02/25/98 PARAMETER ---- SAMPLE RESULTLI h;ITS-- 0 Total Coliform Bacteria ABSENTi PH 6 . 8 146 300 Conductivity (micromhos/cm) 0 . 3 Iron (pPm) 0 . 1 . 2 1.0 . 0 3 Nitrate-Nitrogen (pPm) 20 . 0 Sodium (ppm) 14 0 9 1 . 3 Copper (PPm) 5 . 0 Ammonia (ppm) < 0 . 1 BASED ON THE ANALYSES PERFORMED THE FOLLOWING ADVISORIES ARE GIVEN : * Water sample meets the recommended limits for drinking water of all above tested parameters . Thomas F. Bourne , Laboratory DireCt.or Barnstable County Health and Environmental Laboratory Superior Court House, Route 6A P.O. Box 427 Barnstable, MA 02630 (508) 362-2511 ext. 337 Volatile Organic Analysis Analytical Method: 502 . 2 Collection Date: 02/25/98 Date Received: 02/25/98 Analysis Date: 03/06/98 Client: H. HILLER Mailing H. HILLER Sample Location: 139 Address: P 0 BOX 250 REGENCY DRIVE CENTERVILLE MA 02632 MARSTONS MILLS Sample ID: 714001 Laboratory ID: 714001 Sample Description: PRIVATE WELL Compound Amount MCL Reporting Detected (ug/L) (ug/L) Limit (ug/L) Benzene BRL 5. 0 0. 5 Bromobenzene BRL 0. 5 Bromochloromethane BRL 0. 5 Bromodichloromethane BRL 0. 5 Bromoform BRL 0. 5 Bromomethane BRL 0. 5 n-Butylbenzene BRL 0. 5 sec-Butylbenzene BRL 0. 5 tert-Butylbenzene BRL 0. 5 Carbon tetrachloride BRL 5. 0 0.5 Chlorobenzene BRL 100 0. 5 Chloroethane BRL 0. 5 Chloroform 0. 5 0. 5 Chloromethane BRL 0. 5 2-Chlorotoluene BRL 0. 5 4-Chlorotoluene BRL 0. 5 Dibromochloromethane BRL 0.5 1, 2-Dibromo-3-chloropropane BRL 0. 5 1, 2-Dibromoethane BRL 0. 5 Dibromomethane BRL 0. 5 1, 2-Dichlorobenzene BRL 600 0. 5 1, 3-Dichlorobenzene BRL 0. 5 1, 4-Dichlorobenzene BRL 5. 0 0. 5 Dichlorodifluoromethane BRL 0. 5 1, 1-Dichloroethane BRL 0. 5 1, 2-Dichloroethane BRL 5. 0 0. 5 1, 1-Dichloroethene BRL 7 . 0 0. 5 cis-1, 2-Dichloroethene BRL 70 0. 5 trans-1, 2-Dichloroethene BRL 100 0. 5 1, 2-Dichloropropane BRL 5. 0 0. 5 1, 3-Dichloropropane BRL 0. 5 2 , 2-Dichloropropane BRL 0. 5 1, 1-Dichloropropene BRL 0. 5 cis-1, 3-Dichloropropene BRL 0. 5 trans-1, 3-Dichloropropene BRL 0. 5 Eth lb y enzene BRL 700 0. 5 Hexachlorobutadiene BRL 0. 5 BRL: Below Reporting Limit MCL: Maximum Contaminant Level 4 1 . '4 page 2 Sample ID: 714001 Laboratory ID: 714001 Compound Amount MCL Reporting Detected (ug/L) (ug/L) Limit (ug/L) ISOPrOpylbenzene BRL 0. 5 4-Isopropyltoluene BRL 0. 5 Methylene chloride BRL 5. 0 0. 5 Naphthalene BRL 0. 5 Propylbenzene BRL 0. 5 Styrene BRL 100 0. 5 1, 1, 1, 2-Tetrachloroethane BRL 0. 5 1, 1, 2 , 2-Tetrachloroethane BRL 0. 5 Tetrachloroethene BRL 5. 0 Toluene 0. 5 BRL 1000 0. 5 1,2, 3-Trichlorobenzene BRL 0. 5 1,2,4-Trichlorobenzene BRL 70 1, 1, 1-Trichloroethane 0. 5 BRL 200 0. 5 1, 1, 2-Trichloroethane BRL 5. 0 0. 5 Trichloroethene BRL 5. 0 Trichlorofluoromethane BRL 0. 5 1, 2 , 3-Trichloropropane BRL 0. 5 1,2, 4-Trimethylbenzene BRL 0. 5 1, 3, 5-Trimethylbenzene BRL 0. 5 Vinyl chloride BRL 0. 5 Total Xylenes 2 . 0 0. 5 BRL 10000 0. 5 BRL: Below Reporting Limit MCL: Maximum Contaminant Level Thomas F. Bourne, Laboratory Director Vl TOWN OF BARNSTABLE LOCH--qON \�-!Ci -tZN)C�.A VW-, SEWAGE # VILLAGE "\etc ASSESSOR'S MAP & LOT C5 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNERti[1�1�-�.1U SATE: �Z3\26 U COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 20 Feet Private Water Supply Well and Leaching Facility (If any wells exist i on site or within 200 feet of leaching facility) s0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist t within 300 feet of leaching facility) Feet Furnished by t1,-)-kZ-aCJ\(-10 JVL e