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HomeMy WebLinkAbout0439 REGENCY DRIVE - Health E= 064 ENCY DRIVE, M. MILLS 030 i Commonwealth of Massachusetts ,,t� Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive , Property Address Sheila&David Stagman Owner Owner's Name / information is Marstons Mills y Ma 02648 7-17-2020 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 A. Inspector Information f4��3 filling out forms on the computer,use only the tab Daniel Hawkins key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 u� Company Address Sandwich Ma 02563 City/Town State Zip Code ram (508)477-0653 S114324 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. N Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins Digitally signed by Dan Hawkins Date:2020.07.2215:0434-04•00' 7-17-2020 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 f Y p 9 p o Y 9 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts _....�n Title 5 Official Inspection Form _ �= 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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: ■❑ 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. The original permit dated 4/5/1975 shows a 2 bedroom / 200GPD design. Dwelling has 4 actual bedrooms. Bedroom count does not effect pass/fail of system but local Board of Health should be consulted on the allowed number of bedrooms. 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 1 ° Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced p ❑ 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: l5insp.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 ii� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is required for every Marstons Mills Ma 02648 7-17-2020 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 ❑ 0 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 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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 ❑ El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ a 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ El 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. ❑ 0 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.] ❑ P The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 III Commonwealth of Massachusetts Title 5 Official Inspection Form . , 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ( � 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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 ❑ 0 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? Have large volumes of water been introduced to the system recently or as part of El El this inspection? Q ❑ 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? Fx� ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? E ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ El Existing information. For example, a plan at the Board of Health. 0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Ti Sewage tle 5Official Inspection Form Susurface Disposal System Form -Not for Voluntary Assessments 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 2 Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 200/GPD Description: Taken from permit dated 4-5-1976 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes E] No Does residence have a water treatment unit? ❑ Yes f 7m No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes [E No Water meter readings, if available (last 2 years usage (gpd)): See below Detail: 2018- 56,000gallons 2019- 59,000gallons Sump pump? ❑ Yes NO No Last date of occupancy: currentDate t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form lie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive V� Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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): I Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): l 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 tc 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 4/2019 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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 El 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: 1975 per permit Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): 31 Depth below grade: feet Material of construction: ❑cast iron ❑■ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 439 Regency Drive "+ Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 21 Depth below grade: feet Material of construction: ❑Q concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) I i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No allons Dimensions: 1000 9 411 Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle �J 1511 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 not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 J Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k / 439 Regency Drive Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 required for every page. City/Town 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 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �n ,,p Title 5 Official Inspection Form ±= la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 439 Regency Drive t,— Property Address Sheila& David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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): 0" 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. D-box had some light scaling but is water tight and did not show sign of past back up. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive V Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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 um chamber, condition of pumps and( pump p p 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: (1 6'x6' pit ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ( � 439 Regency Drive u Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 required for every page. 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 hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Pit was 3/4 full when viewed with no higher staining. r 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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.): l5insp.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 _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive u Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts �a Title 5 Official Inspection Form �1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive V Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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 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: Q hand-sketch in the area below ❑ drawing attached separately A9- B1.901" A2.24 M 132.25'5" B Garage I—A L 01 I I I Driveway I Q I , t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive V Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope Surface water 0 Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 12'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) 0 Accessed USGS database-explain: You must describe how you established the high ground water elevation: A USGS topo map was used to determine high groundwater. Water is greater than 12' in area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �= w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 439 Regency Drive ,V Property Address Sheila&David Stagman Owner Owner's Name information is Marstons Mills Ma 02648 7-17-2020 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. ❑i 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 l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 John Septracic D.E.P. Title V Septic Inspector P.O. Box2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor y ARGEO PAUL CELLUCCI a Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,9p � `I 3 9 CERTIFICATION /� Fe Property Address: 4 Regency Dr.Marstons Mills Lx:� 1� Address of Owner: Fe�'� j998 Date of Inspection: 5/5/97 (If different) Name of Inspector: John Graci Jack Nesbit 6� / I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) A 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: X Passes This Inspection Is based on criteria dented In We V — Conditionally Passes code 319 CMR 16303.My findings are of how the system is performing atthe time of the inspection.My inspection does — Needs Further Evaluation By the Local Approving Authority not Imply anywarrentyor guarantee of the longevity ofthe ails septic system and any of its components useful life. Inspector's Signature: Date: wwu The System Inspector sh II submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information 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. COMMENTS: 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of CdThpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised O 27)97) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 is Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4 Regency Dr.Marstons Mills Owner: Jack Nesbit Date of Inspection:515/97 _ Sewage backup or.hreakout.or. hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: 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 watersupply 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 the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] 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 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. Yes No _ — 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. SAS is in hydraulic failure. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4 Regency Dr.Marstons Nmis Owner: Jack Nesbit Date of Inspection:515197 D]SYSTEM FAILS(continued) 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 112 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: You must indicate either"Yes"or"No"as to each of the following: 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: 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. (reylsed=7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: a Regency or.Marston Mills Owner: Jack Nesbit Date of Inspection:515197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — 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. — x As 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. _y_ — 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 The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)] (revised 00V97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4 Regency Dr.Marstons Mills Owner: Jack Nesbit Date of Inspection:515197 FLOW CONDITIONS RESIDENTIAL: Design flow: 22D g•p•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 2 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:(last two(2)year usage(gpd): n1a Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 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) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last two years. System pumped as part of inspection:(yes or no)Yes Reason for pumping: maintenance.If yes,volume pumped: gallons TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy 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 all components, date Installed(if known)and source Information: 1977 Sewage odors detected when arriving at the site:(yes or no) No (reylsed 04127)97) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Regency Dr.Marston Mills Owner: Jack Nesbit Date of inspection:515197 SEPTIC TANK: x (locate on site plan) Depth below grade: 2.6 Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: l.e'e^He'7^w4'tn" Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:15" l How dimensions were determined: nra 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.) The septic tank and all components are aWcturaly sound.Recommend pumping the system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: nfa Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: nla Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:nfa Distance from bottom of scum to bottom of outlet tee or baffle:nla Date of last pumping;, Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) nfa BUILDING SEWER: (Locate on site plan) Depth below grade: nra Material of construction: x cast iron_40 PVC_other(explain) Distance from private water supply well or suction IineNa Diameter: nla Qr mments:(conditions of joints,venting,evidence of leakage,etc.) (revised U2767) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Regency Dr.Marston Mills Owner: Jack Nesbit Date of Inspection:515197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Capacity: rda gallons Design flow: nra gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: rda Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) nfa PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) rda (revised 04127l97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Regency or.Marstons Mills Owner: Jack Nesbit Date of Inspection:515197 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: rda Type: leaching pits,number: 1A00 gallon leach pit leaching chambers,number:rda leaching galleries,number: rda leaching trenches,number,length: rda leaching fields,number,dimensions:n1a overflow cesspool,number:nla Alternate system: wa Name of Technology:_nra Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) The overflow Is structurally sound and"etloning properly.It was 314 full at the time of the Inspecdon. CESSPOOLS: (locate on site plan) Number and configuration: rya Depth-top of liquid to inlet invert: nla Depth of solids layer: n1a Depth of scum layer: rda Dimensions of cesspool: rda Materials of construction: rda Indication of groundwater: nia inflow(cesspool must be pumped as part of inspection) rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nIa PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: rda Depth of solids: n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda (revlsed 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P rope rty Address: 4 Regency Dr.Marston MBs Owner: JUsN Date of Inspection:51519? SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 1W a owel + (Do N r� DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USG$Maps and Charts (revised 1U15195) 9 .4* SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4 Regency 9 Y Dr.Marsta ns Mills Jack Nesbit 515197 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (rav1ssd04WM7) sage to of 10 Commonweatth of MOssoChusetis John Grad Executive Office of ENromvintai Affairs D.E.P. Title V Septic Inspector Department of P.O. Box 2119 EnVIronmental Protection T x 536 � �� u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO y PART A � CERTIFICATION s� '? Ga Property Address: 4 Regency Dr. Marstons Mills Address of Owner: Date of Inspection:515197 (If different) Name of Inspector:John Gracl Jack Nesbit f 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: X Passes This Inspection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is performing at the time of the Inspection.My Inspection does _ Needs Fu er aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of its components useful life. i Inspector's Signature: Date: 51e197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A. B,C,or D: A] SYSTEM PASSES: X I have not found any information 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 lank 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: 4 Regency Dr.Marstons Mills Owner: Jack Nesbit Date of Inspection:515197 _ 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. SAS is in hydraulic failure. (revised 11115195) Z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4 Regency Dr.Marston Mills Owner: Jack Nesbit Date of Inspection:515197 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 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 4 Regency Dr.Marstons Mllls Owner: Jack Nesbit Date of Inspection:515197 Check if the following have been done: X Pumping information was requested of the owner,occupant,and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n►aAs built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was 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. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4 Regency Dr.Marstons Mills Owner: Jack Nesbit Date of Inspection:515197 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 gallons Number of bedrooms: 2 Number of current residents: 2 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: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:9 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: iva Last date of occupancy: n1a OTHER: (Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last two years. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 2000 gallons Reason for pumping: Maintenance. TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool 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: 1977 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: 4 Regency Dr.Marstons Mills Owner: Jack Nesbit Date of Inspection:515197 SEPTIC TANK: X (locate on site plan) Depth below grade: 2.5 Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23' Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 15 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.) The septic tank and all components are structurally sound.Recommend pumping the system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n/a Scum thickness:rVa Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: 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 11/15195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Regency Dr.Marstons Mills Owner: Jack Nesbit Date of Inspection:515197 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: rVa 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: n1a 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.) Na (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Regency Dr.Marstons Mills Owner: Jack Nesbit Date of Inspection:515197 SOIL ABSORPTION SYSTEM(SAS):% (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: n1a Type: leaching pits,number: 1,000 gallon leach pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) The overflow is structurally sound and functioning properly.K was 314 full at the time of the inspection. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: nia Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) n1a t Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) n1a 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 r V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address' 4 Regency Dr.Marston Mills Owner: Jack Nesbit Date of Inspection:515197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (T U S ` DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) g ( 2 - -I LOC&.Tlo N " 5EWaC;E PERMIT UO. VILLAGE — r IMSTQLLER5 U&ME ADDRESS BUILDER 'S Q I MF— QDDRE SS DfaTE PERNA T ISSUED DATE COMPLI W-ACE ISSUED . `� �� I l I 1 O 5Do IJ ,r 3 v No.---- ....... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH , A Wes....... ---r- r OF.......�.... ..... ... ... ..... ..................................... Apphratinn -fur Uiipuiitt1 Worko Tonfitrnrtinn Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: � P�- JP� Psi CLIO, A/ Di,s Location-Address — e f h..(. 1i ... � '�_��..f�l /tt* / fi %h i`� O�wjner. . T /�//�/y Addr{�s "'d �...././e.l���® �di�/bI K l a.-:-�AN�/o N.......................................... Installer Address Q Type of Building Size Lot.-J___..!.t: .........Sq. feet Dwelling—No. of Bedrooms------------------------------------_-------Expansion Attic ( ) Garbage°Grinder aOther—Type of Building ............................ No. of persons..-_-._---_---_-_________-_- Showers ( ) — Cafeteria ( ) Q' Other fixturgs ............................ 5. W Design Flow:............... .. ......: _g111Qg pArson per day. Total daily flow______._____ _ ...............---gallons. WSeptic Tank�—Liquid capaci --_..__-____g n 'Length................ Width................ Diameter................ Depth.-._---_-._._. x Disposal Trench—No..................... Width....______ _ "dot I en 4r W/` t7,�- Total leaching area..-------------------sq. ft. Seepage Pit No..... ........ Diameter./t _r eP e o nlet.................... Total leaching area.-__-.__---______sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.--------------........ (1 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.-. --_-_----_------- P1 ---•---------------------- •---- ------••--•-----•--•••--•-----••-•-••----•...._---•--•-••-•...... O Description of Soil----------3:' soy'/........... 4 ••... h� C'ffs�y.--•----• � •x-----. ------------------ -- r�+ Qf v�*2�l /7/•tc0 �. wc4/C>t_ a'nV•/7!10 �' -oJ 197 --•----•-•-•---•-----------•------------------------------dP. . .... ,� W U Nature of Repairs or Alterations—Answer when ap��li'c-.able._-___Gt_. _._. hU _�_;_ " �- ���_0.. 4� r' ,�/Oh,ft- e/r'�cP. n ems' % :s Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beft iss.ed by the board of h lth. r7° S—76 Signed. ..... 4. ........•- - ----------------•------•--- ............ �� Date Application Approved B -- _---'--a�Gyl Ld!1/�_ .---------------- ........ a --,---- PP PP Y .... ;- Date Application Disapproved for the following reasons:................................................................................................................ .................•--.......••-----•••-------•----------------•.......•--------•-•-•------••-•-----'-_---... Date PermitNo......................................................... Issued........................................................ Date ..��-------------_-___--_-__._____.___�_------------------- _ — ---------- -------------------� No...... ..........--- ........ ............... THE COMMONWEALTH OF MASSACHUSETTS BOARDe H ALTH i'tn/�1 .......... ....OF................................................................................... Apphratiun -fur Bispuiitt1 Workii Tomitrurtiun Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: p TK Loc lion-Add ess p �] orFLot No. Owner Addr ss F ��u t� ------------ -------------- Installer Address Q Type of Building Size Lot...Lc?.e r e---------Sq. feet Dwelling—No. of Bedrooms..--..__`L-------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------ -- Desi n Flow........... .......<,1______-_______-----..gallons per person per day. Total daily flow--_-.----Z--__-._----___-__ W g g P P P Y Y gallons. WSeptic Tank—Liquid capaci�v�..gallons Len-th---------------- Width................ Diameter_....__..-_----- Depth.__._.._-.----- Disposal Trench—No. .................... Width___..___.___ ._ to Le h��----. ---_ Total leaching area-------------.------sq. ft. Seepage Pit No-----I............... Diameter/ b 1 cA inlet_.................... Total leaching area.----..----._-____sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date--------------------------------------- ,� Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water_..._--._-----..--.----- �, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__._-.-._--_-_-.---_-. a ----•------------------------------•-----•-----•------- ---------•-------------•-•---•---------•--- G Description of Soil.--------- d ! 2 'pN tifs C/ ------- , Y7 7- - - -------------------------------------------------------- ............................................................ ... < .............W U Nature of Repairs or Alterations—Answer when applicable.__-__.r-� .___ �d/n f___ yl---3_ _`_,__Tu'^h_._ .___... -# �A -bra_f; --------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b iss ed by the board of he lth. Sign .._ . .---• •-•---•-•--(/t__` ................................ Application Approved B -- /� `.. f�/, Date - PPPP Y --- - ------------------- ------------------- -..---------------- Date Application Disapproved for the following reasons------------------------- - ------ - ---•---------------------------------------------------------------- ---------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS // BOARD OF HEALTH ...........OF................ ........... ✓ ( ....................................... . ..... Trrtifirate of Tomphattre THIS IS TO CERTIFY, Thg.t,tne Individual Sewage Disposal System constructed ( ) or Repaired ( }� Installer at-----------/` l!�'�`'`,r. - „ Jl - - rrl 7 �` has been installed in accordance ith the provisions of : cle XI of The State Sanitary Cocl a_s de- cribed in the application for Disposal Works Construction Permit Nov-__. �.. :................... dated­__y � __7� THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A G✓)_A,R�7ANTEE THAT THE SYSTEM WILL`FUNCTION SATI FACTORY. DATE----------- -----------76.--.....- ................. Inspector------ -��--------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r� ...............�..d..Wv!...........O F................ram'........:�-�-!.....------------•----................. b No......................... FEE---- ....... �i��u�rtf ', u k,� nun tr�trtiutt �rrmtt L . Permission is hereby granted_________________ ---------- --- ----`--- ---- --- to Construct ( ) r Repai" ( - n Inyi ideal Sewage DispO�al System---------------------------------------------------------------------- atNo. - ------1 ----------------- ------=-=1----------------------------------------------------------------- Street �/,7/ as shown on the application for Disposal Works Construction Pqrmi ated...... ..'...._............................. Board of He DATE1 '............................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS K �l �Ile, Y U 3,b No...............j....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH_ WoAppliration for Disposal Works Tonstrurtion Pumit Application is hereby made for a Permit to Construct (41�0'or Repair ( ) an Individual Sewage Disposal _System at: .......... ••. .. ..... ..... ... ---- `---------------=/�+"....-- --- ----- -----9',---• -.....-------------------•--.._....-------•___-----•---.. Locat y -A dress rle NV y� t .... _ ..... � .�I.. ............................. _A____� ` Owner A e ess U Type of Building Install StzderLot_ feet Dwelling-k-No. of Bedrooms_..._ Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------•-----•----------------•---•-•---••---.................................................. W Design Flow Or-4 allons per person per day. Total daily flow._.__.____ gallons. WSeptic Tank t Liquid capac t/ allons Length................ Width---------------- Diameter____-___-_..___ Depth__-__________-_- x Disposal Trench—N .: ............ Wid h___________ ___ _ otal ngth___ ._..... _ Total leaching area--------------------sq. ft. `� Seepage Pit No....�.________ Diameter:_ ..... epth b o in et_____________ _____ Total leaching area_______-____..____sq. ft. Z Other Distribution box ( ) Dosing tank ) '~ Percolation Test Results Performed by.. "' ��te---4?4,C- ------ �f 7-3 Pit No. 1________________minutes per inch Depth o Test Pi .____._.________._.. Depth to ground water_ ---------- Test �14 Test Pit No. 2................minufe-s pee; itac4�. De h of Test„Pit.............. Depth o ground water_______ ___ O Description of Soil---------------- �} -- --a' -------------------------------------------------------------------------------------------------- x U w x -•--•--•••------------•• ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: ------- -------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue b he board 0. ealt . Sied............_. ,4E.r...... fl .. ................................ Application Approved B ate PP PP Y - $ __3 Date Application Disapproved for the following reasons------------------------------- ----------------------•------------------------------------------------ je/,7/,&a'te - -- -------------------- -------- ------- Date •-------------•--•---- Issued--- �- Permit No. < ---..------ No...... `s--...- -•---- Fla1a.. ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH ......7r'_ ............oF......iZ' . � .. ......... ... Appliration' for Diq#lagal Works Tomitrurtion Prrmit Application is hereby made for a Permit to Construct ( r Repair ( ) an Individual Sewage Disposal Sy tem at / r* 6LNaA Locati6lr-A dress or No ti Owner Address --------------- Installer Address Q Type of Building Size Lot____________________________Sq. feet Dwelling 4-No. of Bedrooms.......... --------------------------------Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons.._____-____-_______________ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------ W Design Flow......................` '_"= _..•..._.gallons per person per day. Total daily flow................ '". _.____._.____gallons. WSeptic Tank Liquid capacit�,�€`� .._gallons Length.............:.. Width------------.--- Diameter..__._ --------- Depth_____._---_----- x Disposal Trench—No_____________________ Wiil}h__ otal ngth Total leaching area-------------------- ft. Seepage Pit N ... ----------- Diameter .. A b ' nreti __ Total leaching are a------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b �_ -._ v.,.._ � t { � f -.7. a Y-- ---- � - --�---�.„�- �' '` ---- Date---:--�- ---;��:;----�' �� a Test Pit No. 1................minutes per inch Depth o Test Pi __________......... Depth to ground water.. ___`_--___ : - �14 Test Pit No. 2................minu'res per incll_De ,h of Test"Pit................... Depth o ground water-------- -__-. Description of Soil--------------- " :ar .«�. -------- U ---•••-•---------•---•-•-•---------- ----------------------------------------------------------------•------------------------------------------------------------------------------------------------- W VNature of Repairs or Alterations—Answer when applicable._______________________•-----_-_________._____-____--•.-_.------.--.______-__.____..___-___----. ---------------------•-•---------•-••--------------•-----•--•------•-------••-------------•----------•----•---------------------•--••----------------------••----------------- ------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal,System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by he boardpPbeal Si d---••••-.. ` ( " - � Date �.,,.. Application Approved BY � E -aS - �^ -------•------ 3 Application Disapproved for the following reasons:-------------------------------- -------••------------------•-•-------•---------•---- Dat---•----------- ..........................................................----•-------...--••-•---------•-•-••--•--•----•-•--•----•-----•--------------------------------/te -, ------- ------•------------••--- / Date-----.- Permit No. Issued `K { .-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !..; .......OF....... .....€ .. ................. /OkIrrtifutt#r of Tantphatirr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed °(-`�`or Repaired ( ) by.....--- •.................• ---------• ----- ---- -•---------••------------•--•---------------•-•------------ I staller has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works .Construction Permit No....-24,.4 ....................... dated...... '. _":," ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS.A GUARANTEE THAT THE SYSTEM WI L F CTI N SATISFACTORY. DATE --------------------------------- Inspector------•-• 0.0 THE COMMONWEALTH OFMASSACHUSETTS BOARD OF HEALTH ....... ...OF ................... FEE 3 r Permissionis hereby granted...............=........................................'.................................................................... ...------ to Construq or Repair ( ) an Indlvidu 1 Sewage isposal System , ... ,« ,n atNo. = = ...__ , > ------------------------------------------- ,.f Street a, as shown on the application for•Disposal Works Construction Per No. Dated..... ------------ ----------------------------------------------- /� Board of Health DATE------------------------------------------------------------------------=-- � , FORM 1255 HOBBS & WARREN. INC., PUBLISHERS d a - --I ;--- 2-- /¢t,G O ' � G p%' •U 9 1i r) V � In 1y .5- �•5 y f'r rc I .. I 1 0 1 o� v � '.`-� y� L _ ��Jai ��•- �._ 3 T Pf az a � SPTu�-A L t „- a' 4o _4o 5a►,v 4„ owe PLOT PLAN OF LAND IN EH pr2 s"ro Q cz� I L�Ls SCALE: II�� DATE: �AA.R-•Z9 IY73 ZONING REQUIREMENTS. EWAL.D & MASCHI INC. ENGINEERING CONSULTANTS DATE: FRAMINGHAM, MASS. c3P. P. C-1 OGG-4.