HomeMy WebLinkAbout0052 ROSELAND TERRACE - Health 52 Roseland Terrace
Marstons Mills P
- - - - A = 103 118
Commonwealth of Massachusetts 3- Ile 'Talc"
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every _ _._ _
page. Cityrrown 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.
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ay Company Address
West Yarmouth _ MA _02673
City/Town State Zip Code
508-364-4398 _S1623
Telephone Number — License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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
2-24-20
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
In the future under the same or different conditions of use.
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila --
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
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 is a 1500 Gal. Tank D Box and three trenche's. Note: Tank outlet tee has a zable filter.
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.7/26/2010 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
v 52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every _ _ _
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines In accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5lnsp.doo-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 1e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila ------
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance: _ ---
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
El ® 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
tsinep.doo•rev.7126/2018 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
52 Roseland Terrace
Property Address
David Malila _
Owner Owner's Name
information is _Marstons Mills MA 02648 2-24-20
required for every .- -- -
page. City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cunt.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than %day flow A E,4 CtKlN C
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well,
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
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.7/2612018 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
52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills MA _ 02648 2-24-20
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
❑ ® 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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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)]
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 16
t5inap.doe•rev.7/26/2018
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every -- -
page. Cityrrown state Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): - 3 — Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
1500 Gal, Tank D Box and Three Trenche's.
0
Number of current residents:
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 ears usage 2018-65,000Gals
g ( y g (gpd))' 2018-67,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5lnsp.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
52 Roseland Terrace
Property Address
David Malila —
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every State Zip Code Date of Inspection
page. Cityrr wn
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ 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:
NA -
Source of information: —
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: giiions
How was quantity pumped determined?
Reason for pumping:
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
tbinsp.Coc-rev.N2612018
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every _. .. - _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,pp g date installed (If known) and source of Information:
1999 Permit * 99 -620.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain): —
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
_Pi eingis 4" PVC -SCH -40.
15insp.doc rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
uq- 52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is required for every Marstons Mills MA 02648 2-24-20
— — --
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
20"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1500 Gal. Precast H-10
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
27"
3"
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
Asbuilt-Tape
How were dimensions determined? Sludge -Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 20" below grade w/both cover's at 14". In and outlet tee's. Note:
Tank outlet tee has a zable filter. No sign of leakage or over loading. Note: Pumping and cleaning of
filter after inspection. --
mnsp.00c•rev.72e201a Title 5 official Inspection Form:Subsurface Sewage Disposal Syelem•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every _. -_ -
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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. % 52 Roseland Terrace _
Property Address
David Malila _
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
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):
Depth of liquid level above outlet invert 0 -
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x21"40" below grade w/three line's out. Box is solid w/no sign of over loading or solid
carryover. _
Mnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systom•Page 12 of 10
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 52 Roseland Terrace
Property Address
_David Malila
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every — - _
page. Cityrrown 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.):
*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: 3
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: —
t5111sp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila
Owner
Owner's Name
information is required for every Marstons Mills _ MA 02648 2-24-20
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.):
Leaching is three trenche's. Ck box prob area. Camera out line's . Pipeing and hole's clear w/no
sign of holding water. No sign of over loading or solid carry over.
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.aoc•rev.7128@01a 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
52 Roseland Terrace
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills MA 02648 _ 2-24-20
required for every _
page. Cityr town State Zip Code Date of Inspection
D. System Information (cost.)
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.):
t5inep.doo-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila _
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
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:
® hand-sketch in the area below
❑ drawing attached separately
G)NRA t
P-1 7/�i L
F,
Winap.doo•rev.7/2 6120 1 6 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Roseland Terrace
Property Address
David Malila _
Owner Owner's Name
information is Marstons Mills MA 02648 2-24-20
required for every ---
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
M0 10'+
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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Lot and leaching area 10' higher then road. Bottom of field at 5'below grade. Bottom of field at 5'
above road.
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Roseland Terrace_
Property Address
David Malila
Owner Owner's Name
information is Marstons Mills _ _ _ MA 02648 2-24-20
required for every _
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® 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
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R �RR
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15insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE ,.G
LOCATION4o� �Sl/4n� /es —, SEWAGE #
VILLAGE ftl ErAy s Ifi 5 ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (9r) re (size),
NO.OF BEDROOMS
BUILDER OR OWNE
PERMTTDATE: !—COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
��
3� �
o ay �t3 a► `��
�a� ���
Town of Barnstable P# V
Department of Health,Safety,and Environmental Services
o�WE Public Health Division Date
Q„ 367 Main Street,Hyannis MA 02601
� BARNB'rABlE,
MA99.
16
19. ��
lEot " Date Scheduled Time Fee Pd.
Soil Suitability Assessment forSewage Disposal
Performed IIy: OAAf f}C.,,V G:40 d(XbrICUt "50 GMC. Witnessed By: �/1lkt /'t l YYewe�tt
...
LOCATION& GENERAL INFOR''MA I,ON
Location Address Owner's Name
Address GC111-C V1f6
Assessor'sMap/Parcel: /(/���$ Engineer'sName�r
NEW CONSTRUCTION REPAIR Telephone# 0w
Land Use Reg%J&VA-WO Slopes(%) Z e Surface Stones A/0/V-e
Distances from: Open Water Body NTIt Possible Wet Area k�/+- R Drinking Water Well !NgYMAJ
Drainage Way N0 R Property Line 15 ft Other !t
-A liv-5 AQ!EA IS S41ZoEV Sk/ TocmIQ wA'V(.IZ
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
I z /►'
T�Z
G ~
6�
N
125 t '
:RMCf
Parent material(geologic) Depth to Bedrock
Depth to Groundw ter: Standing Water in Hole:tVO-A-'L— Weeping from Pit Face 4✓v��
Z,,�f* 4/J.�
Estim easonal High Groundwater If
..............:. _:..,.....,: :::.: ::.:...: . ..:..... -::..:.:..:.......ETEV . O 'OALGD:....�.,:A. TER....;T...A�LRNA R *;
`
.. .
Method Used No W 6Td (L
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well#_.__._._. .Reading Date:_. Index Well level.__._ Adj.factor Adj.Groundwater Level
.
::.
.........:.>: . . : t'ER+COLATTON :mate z; /I
Observation
Hole#` ' Time at 9"
Depth of Perc �1G 0 Time at 6"
Start Pre-soak Time @ / 3 M�N Time(9"-6")
End Pre-soak Aturl, C4 4 V I/�''�,1
Rate Min./Inch 0"� '�1TVA r4�t
Site Suitability Assessment: Site Passed_X Site Failed: Additional Testing Needed(Y/N)
Original; Public Health.Division Observation Hole Data To Be Completed on Back j
Copy:. Applicant
DEEP OBSER ttATIOPd'HOL LO+G
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,° Gravel)
n f 4 a rtt /0YP-'/Z, v 14 d�P
If L4j4OA 6 y No N1 ICirAel
30-1(0 t S Z,J`I 7/
36 -7Z CZ SIC �° z.Sy� ►1
IC aW sY �z_
DEEP{OBSERVATIONHOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
0- 1 d c o A- Lvt� /0 yp L x tq b
LP -7`'f Ct M*4 cse 2'�y 6 LA:.os�
V-52- �Z 7/7
DEEP;OBSERVA'7'IO�T HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,°o ravel
DEEP OBSJE TION 110LE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color ' " Soil Other '
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistenc %Gravel)
Flood Insurance Rate Mao:
Above 500 year flood boundary No_ Yes
._ Within 500 year boundary No Yes
Within 100 year flood boundary No_ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption systeim?
If not,what is the depth of naturally occurring pervious material?
Certification 4
I certify that on 1 (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was perfo ed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017. TKOL AQA AAY
9 Ql N ltt NGL W rtTt .. tAYtL.-5
l "t'mix (zoo( ) t'r' Got.1.10
Signature V Date 3 Z
A(�cct- Aiti5 5Y5'1`r M
No. 7 ' a , Fee
3 �g THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Migogal *pgtem Congtruction Permit
Application for a Permit to Construct(✓)Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. &1 &1101V 1V,QQ(le Ownemee,Addr s nd e,.,No.o.
��iy�/� �[n
Assessor's Map/Parcel/015 //8 \!/3 e 0-ap Sf., h Q Ivis //O''To199
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
J.k. Hol � �o Ui 0-11�o0
, h / f
Type of Building:
Dwelling No.of Bedrooms Lot Size M#Pe sq.ft. Garbage Grinder( )
Other Type of Building &)tl0 YQQe No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow " 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /f IJ) - �P PL/ %A�QPC D/Qn
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and ntenance of the afore described on-site sewage disposal system
in accordance with the provisions-of`Yi e t Enviro ntal Code and not to place the system in operation until a Certifi-
cate of Compliance has bee sued byt e ^
Sued v Date
Application Approved by Date 9,-at-�°P
Application Disapproved for Ye foll ing reasons
Permit No. A Date Issued
No. "^ s� 3... Fee d
°
—140000,
I / % /_ ` ° Entered in computer:
:g THE COMMONWE�►IJKWPF MASSACHUSETTS
Yes
PUBLIC HEALTH DIVISION -TOWN OFBARN TABLE, MASSACHUSETTS
Zlpprtcation for ;DtgposW_6piteft Construction Permit
00
Application for a Permit to Construct(✓)Repair( ),upgrade( )Abandon-( )"e.f]❑ '9mplete System ❑Individual Components
'Location Address or Lot No. "fie.,,QCve try Owner's Name,Address
Ja d Te No.
Na�sfo)S /��S F S�io��e
Assessor's.Ma0arcel F/..3
Installer's Name,Address,and Tel.No. Designer's Namd,Address and Tel.No.
sk. NF/l, uth
Type of Building:
Dwelling No.of Bedrooms Lot Size We 'sq.ft. Garbage Grinder( )
Other Type of Building�Qn�(1. No. of Persons Showers( ) Cafeteria( )
Other Fixtures `1
Design Flow h'� gallons per day. Calculated daily flow � gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) L!) - 11 S /lPP 0,00 JA 00,C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and aintenance of the afore described on-site sewage disposal system
in accordance with the provis was- t e f Enviro ental Code and not to place the system in operation until a Certifi-
cate of Compliance has � sued b ^
Siaea_d Date
Application Approved by _ Date
Application Disapproved for e fol ng reasons
l Permit No. - G Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
r � - Certificate of Compliance
THIS IS TO CE , t at th Tite Sewage Das sat
Construr�ted ac^) a aired (, ) pgraded( )
Abandoned( )by 1 , M. C' )�A
at h s been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N . dated
Installer Designer
The issuance of this permit s a 1 n t��Jued as a guarantee that the will function esi ,r
Date InspectorILI
U"I/ �)
--=l —/-----------------------------------
No.Z7 — (� r�) Fee �D d
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Diz poof *pgtem Contruction Permit
Permission is hereby granted to Construct(Nel)Repair( )Upgrade( )Abandon( )
System located at ! �, �_ �.r" til /Vl
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be comp ted win three years of the date of e
Date: Approved b i
J PP Y
�j
TOWN OF BARNSTABLE
LOCATION /.
�� �Se .� /eri, SEWAGE # ..
c ++
VILLAGE—MA r-A,AJ s i l 5 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (ty (size)
NO. OF BEDROOMS
BUILDER OR OWNE
PERMTTDATE: w�o
COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
N
I
j.
i
�n
r
a�n r?
• b
y�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION ��
2
TITLE 5 �
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS G`
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A ��
CERTIFICATION �' r
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648 �� J i l� LQ*Q,
Owner's Name: JIM STEIDLER ; l '
Owner's Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648
Date of Inspection: 11/19/01
ED
kEC
Name of Inspector: (please print), c JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 DEC
Telephone Number: 508-564-6813 FAX 508-564-7270 -TOWN OF gARrlS(.
HEALTH DEPT \
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 the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes ;
is YF+
_ Conditionally Passes `°
Needs Furth valuation by the Local Approving Authority
_ Fails ' ?
inspector's Signature: Date: 11/19/01 4
The system inspector shall subm a copy of this inspection report to the,Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
t .x Jr i
sent to the system owner and copies sent to the buyer, if applicable,and the.approving authority. .
RiF
Notes and Comments 4
SYSTEM PASSES TITLE V INSPECTION . RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
f•"Ak tiM
****This report only describes conditions at the time of inspection and under the conditions of use at that thee,This Y
inspection does not address how the system will perform in the future under the same or different conditions of use.
Title 5 Incnrrtinn Fnrm ril snnnn I `•+' ` "
Avi
Page 2 of 11 .
t
OFFICIAL INSPECTION FORM—NOT FORYOLUNTARY ASSESSMENTS x
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :
PART A h �
CERTIFICATION (continued)
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648 t
Owner: JIM STEIDLER
Date of Inspection: 11/19/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D w
A. System Passes: "
X I have not found any information which indicates that any of the failure,criteria described in 310 CMR 15.303 or in 310 4
CMR 15.304 exist.Any failure criteria not evaluated are indicated below. W,W
b �
Comments:
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
• 7 S � 'c �4ryr.;
SYSTEM'S USEFUL LIFE. ,
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass. IWA
+3
d�b
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. ¢{ :
n/a 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 x
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' A _'
that the tank is less than 20 years 616 is available. - `
ND explain: n/a
n/a Observation of sewage backup dribreak 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): # 4`
_ broken pipe(s)are replaced k , .
_ obstruction is removed ' � ?•
_ distribution box is leveled or replaced
ND explain: n/a
i n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass cr ,
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
,__•�• ;.,fit ���..
F� W
A�?
h F. .
Page 3 of I I , ,{
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART Ar.:
CERTIFICATION(continued)
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648
Owner: JIM STEIDLER
Date of Inspection: 11/.19/01
C. Further Evaluation is Required by the Board of Health: '
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment. �G
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system isy "
not functioning in a manner which will protect public health;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 marshy
t ,�
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the .
system is functioning in a manner that protects the public health,safety and environment: `''
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply. t
_ 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 n/a }$ y
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and rt
volatile organic compounds indicates that 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,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
7 t
3. Other:
n/a AQ
° ra
f
F
`w
Page 4 of 11
F
OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS !
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM } �
i
PART A g .
� r .
CERTIFICATION(continued)
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648
Owner: JIM STEIDLER
Date of Inspection: 11/19/01 Y i4
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections: F.
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged :_
SAS or cesspool ` x
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool w
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow :
X Required pumping more than 4 times in the last year Nt7T due to clogged or obstructed pipe(s).Number of times, x
pumped nLa. �
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone I of a public well. � �
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. 6 `
X 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 asses if the well water analysis,performed at a DEP
p q Y Y I Y p Y �
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free 3 t
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to ors
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
*ice 1
attached to this form.) 's
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 k" '
CMR 15.303,therefore the system°fails:-The system owner should contact the Board of Health to determine what will be r
necessary to correct the failure.
E. Large Systems: g
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. rF
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply .
_ X the system is within 200 feet of a tributary to a surface drinking watersupply
X 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 ,
A,
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered q _
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threatr
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate re ional office of the Department. "
g p
R
I
Page 5 of 11
:..' t .,
r4..u,.
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B `
ryq`
CHECKLIST
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648 xR
Owner: JIM STEIDLER '��
Date of Inspection: 11/19/01
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
Yes No �
X _ Pumping information was provided by the owner,occupant,or Board of Health
�k
X Were any of the system components pumped out in the previous two weeks? }
X _ Has the system received normal flows in the previous two week period? {
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) a `ypE
Y.z'-2,�,,��,
X _ Was the facility or dwelling inspected for signs of sewage back up? °L
X _ Was the site inspected for signs of break out'? t
X _ Were all system.components,excluding the SAS, located on site?
Y P � g -�`•� �;
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the fi�w
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance 3;i
of subsurface sewage disposal systems'? ram.
x s
i
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ 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(3)(b)] tL
�.
d Kh
a
t t
a �
r
A
Page 6 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS "
SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM
PART C . .
SYSTEM INFORMATION
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648
Owner: JIM STEIDLER
Date of Inspection: 11/19/01 W
FLOW CONDITIONS `
ry q
RESIDENTIAL � z
Number of bedrooms(design):.3 . Number of bedrooms(actual): 3 ��
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO n"$
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] k .
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NOr .
Last date of occupancy: n/a
COMMERCIALANDUSTRIAL
Type of establishment: n/a {
Design flow(based on 310 CMR 15.203): n/agpd Z'�.,�
Basis of design flow(seats/persons/sgft,etc.): n/a
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): NOi`'
Water meter readings, if available: n/a rr
Last date of occupancy/use: n/a ,
OTHER(describe): n/a z '
GENERAL INFORMATION + � a
Pumping Records
Source of information: n/a - 1
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons How was quantity pumped determined?n/a r' '
Reason for pumping: n/a
TYPE OF SYSTEM ,
X Septic tank,distribution box,soil absorption system '
_Single cesspool
Overflow cesspool z � '
_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 tis�
system owner) `
_Tight tank Attach a copy of the DEP approval e
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information: hY
fi ,1 Ctt�t` .i
2 Y RS- 1999 ,:
Were sewage odors detected when arriving at,the site(yes or no):NO `
Page 7 of 11 ,
} �
h3 f
s
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C *_ :=
SYSTEM INFORMATION(continued)
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648 }'`5
*
Owner: JIM STEIDLER
Date of Inspection: 11/19/01
BUILDING SEWER(locate on site plan) y -"
Depth below grade:30" <
Materials of construction:_cast iron X40 PVC_other(explain): n/ar
Distance from private water supply well or suction line: n/a
4
a ,
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan) ''
4 ,
Depth below grade:24"
P
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10 6 H_5 6 W 5 8....
,f :
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33" 4 t°
Scum thickness: 1" �"•'�`
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17" . ;
How were dimensions determined: MEASURED a t
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related 4
to outlet invert,evidence of leakage,etc.): ,
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. r"
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG.THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan) � R
MA
� .
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a h
Dimensions: n/a +
Scum thickness: n/a •.
Distance from top of scum to top of outlet tee or baffle: n/a '
Distance from bottom of scum to bottom of outlet tee or baffle: n/a "s
Date of last pumping: n/a "
Comments(on pumping.recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related {�
to outlet invert,evidence of leakage,etc):
n/a a `"
r
4� N
1 ri 6
f ' W
A
Page 8 of I 1 z >•
1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ` '4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C t:. ` :
SYSTEM INFORMATION(continued);L
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648
Owner: JIM STEIDLER :z
Date of Inspection: 11/19/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) s
Depth below grade: n/a 4 zr
Material of construction: concrete metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a `
Capacity: n/a gallons c k
Design Flow: n/a gallons/day r = ,
Alarm present(yes or no): N/A ,z
Alarm level: N/A Alarm in working order(yes or no): NO �' t
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.): A >%
n/a t,
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) ��,
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE4� �
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into F '.
or out of box,etc.):
D-BOX IS STRUCTURALLY SOUND. €
PUMP CHAMBER:_(locate on site plan) ;.
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO :yam xis
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): � .
n/a
a I
!{ti
TAM
S R
:F,•1 Fr"�
Q
Page 9 of 11
-w'iy-lw
r
w:7
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,;`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM = �
PART C
SYSTEM INFORMATION(continued)
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648 `
1)
Owner: JIM STEIDLER
Date of Inspection: 11/19/01
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) at'�
,r
If SAS not located explain why:
n/a
Typ
n/a a leaching pits, number: n/a .
n/a leaching chambers, number: n/a d <'
n/a leaching galleries, number: nla x
0 leaching trenches, number, length: p ° .
leaching fields, number: LEACH TRENCHES
3 g �
n/a overflow cesspool, number: n/aT.
n/a innovative/alternative system `' 1
Type/name of technology: n/a
'AT. ,
V 3
s
Comments note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): t
LEACHING TRENCHES ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a '
Depth of solids layer: n/a n ,
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a Y
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): ''-
n/a
r, 4i}t
PRIVY: (locate on site plan) yt�'
yr ty
Materials of construction: n/a
Dimensions: n/a f
Depth of solids: n/a '2 gat
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): ,
!t ,
i 1 i+•�4T'�L
Y
t
s �
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
t
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648 �
Owner: JIM STEIDLER �
Date of Inspection: 11/19/01
".9
SKETCH OF SEWAGE DISPOSAL SYSTEM '"'
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. d
Locate all wells within 100 feet. Locate where public water supply enters the building. ^
A
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Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS sort"
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM £`
PART C
SYSTEM INFORMATION continued
Property Address: 52 ROSELAND TERRACE MARSTONS MILLS,MA 02648
P Y
Owner: JIM STEIDLER
Date of Inspection: 11/19/01
SITE EXAM
Slope }S
_Surface water
_Check cellar f
Shallow wells
Estimated depth to ground water 9+feet ;,,,. ''
Please indicate(check)all methods used to determine the high ground water elevation: 4
, t
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a ,.. r
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a ;% E
NO Checked with local excavators, installers-(attach documentation) �
h +
NO Accessed USGS database-explain: n/a `
You must describe how you established the high ground water elevation: '
GROUNDWATER DETERMINED BY AUGER-NO WATER AT 9'--BOTTOM OF FIELD IS AT 5'
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WWWW41N,-i
-- -- Design Schedule ELEVATION i Leaching Area Requirements
EXISTING LEGEND PROPOSED ---- ---------- --- 92 00
TOP OF _
Edge of Pavement-- - - 84.25 3 BEDROOMS AT 110 GPD/BEDROOM = 330 GPD
FINISHED BASEMENT FLOOR —__ _ _ _ � _--_�
Serer /
---s --- -- _ FINISHED GARAGE FLOOR NA ADDITIONAL 50� FOR GARBAGE DISPOSAL N A
Vater Plpe --- w -- - SEWER INVERT AT FOUNDATION i 89.90
Drain Pipe — --- --- ------ -----— -
Gas Pipe -------- G SEWER INVERT INTO SEPTIC TANK 86.65 PERC RATE = 2 MIN. / INCH (CLASS I }
Manhole Cover SEWER !NVERT OUT OF SEPTI; TANK — 8650
Catch Basin ■ SEWER INVERT INTO DISTRIBUTION BOX 86.37 L TAR = 0.74 GPD/S.F.
_ _ _ _—tl-
Vater Gate H SEWER INVERT OUT OF DISTRIBUTION BOX - 86.20 — -� i
Light Pole —� MIN. LEACHING AREA OF S.,A.S. .
Utility Pole �- SEWER fNVERT INTO LEACHING SYSTEM - — 86 00 _
-------- - --- - — -
zoos �— BOTTOM OF LEACHING TRENCH
Spot Grade 3a.n 330 GPD/0.74 GPJ/S.F. = 446 S. MIN Contours --- eon
Test Pit - - - --�- � 7Q o -�
WATER TABL E
f— --__-__--__--_ --.—______.__-- __--_-__ __ _ PROPOSED SYSTEM :
l— — - -- I 400 GPD W/LEACHING AREA OF 580 S.F.
GENERAL NOTES:
ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE WITH
TITLE V OF THE STATE SANITARY CODE (310 CMR 15.000) EFFECTIVE
S 51'53'40.. E MARCH 31, 1995 & ANY LOCAL RULES APPLICABLE
1'S,00'
LEACHING - ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING
t 8 '
TRENCHS '-
BY JOHN K. HOLMGREN P E.
RESERVE /AREA WHEN CONSTRUCTION IS COMPLETED AND PRIOR TO BACRALLING,
NOTIFY THE ENGINEER & BOARD OF HEALTH AGENT
FOR INSPECTION,
W
0
FOUNDATION ELEVATION MUST BE CHECKED WHEN COMPLETEC'
�
Z _ LEACHING TRENCHING DETAIL THESE ELEVATIONS MUST NOT BE CHANGED WITHOUT WRITTEN
32' APPROVAL BY JOHN K. HOLMGREN P.E.
'1N BOX J'.>
001 TEST PIT J1 T O
I��''; T SCALE ALt SANITARY DISPOSAL SYSTEM PIPING TO BE 4" SCHEDULE 40 PVC.
C�
1500 GALLON
g1 SEPTIC TANK O
�e� 0 16,0
o o 2'Lover 3/4 to 1 1/2' Cie_-
nj
CD Peastone Washed =tone I P R A
Ao 4,0'
PRIMARY BENCHMARK CENTER BOTTOM STEP HOUSE #6 NECK POND 0 D
20.6 PROJECT BENCHMARKTAG BOLT OF HYDRANT #1 19 ® i 22 WIANNO CIRCLE
# 40 ''� B'0 RESERVE 4' Perk' PV
TEST PIT #2 3 _ 2' _ AREA , 2' LOCATION OF UNDERGROUND UTILITIES ARE APPROXIMATE AND
a Eff. width ztf �ridth SHOULD BE VERIFIED IN THE FIELD BY CALLING
I� ' of N o DIG SAFE @ 1-800-322-4844
�6 PROPOSED BUILDING N) _-
24 TOP= 92.0 `D C) b
- MAP 103
=" 36,0' 91 117
--� t,4 4'Perf, PVC
+ Ppt'pr'�ED
DRIVE
r------24.'---r
. 4
OF Ar#1?
Lu
r.
MAP8103 o ---t2 '-- Di tribution Lines>
0
I 69 be unperforated with
# 52 a Mo wo er .ight joints RESEP,VE DEB
3 APEA
EXEC RISER/CABLE BOX -
N 80-06*30" W
s,
i�YncEOWW 7"E'RRA
Septic Design
52 Roseland Terrace
Marston Mills, Massachusetts
B.M. = TAG BOLT OF HYDRANT No. 1044 PREPARED FOR
ELEV = 85.07 James Steidler
TITLE
— --- - ----—- -- _ - ------ --- -- --- --- ---- Sanitary Disposal System
SYSTEM PROFILE I J.K. HOLMGREN & ASSOCIATES INC.
Finished Grade =91.' TYPICAL S YS T
DATE : 3-23-99
ENGIlNNEER : BOARD OF 14E.-1LTH AGL-N? :
=.I ---- NOT TO -SCALE JX Holmgren Associates Donu M irandi. Bam. Health Lkpt. i J.K. HOLMGREN & ASSOCIATES INC.
Foundation =92.0' TEST PIT of 1 T - I j Registered Professional
G.S.E. = 92..9" __ _ E = 9�.41 " Engineers and Land Surveyors
FINISHED GRADE OVER TANK = 91.5' FINISHED GRACE OVER D, BOX = 91.0' 4650 Falmouth Road, Rt. ?8, COtll1t, 11�1A 0?635
FINISHED GRADE OVER LEACHING TREAVCH = 91F_ I ,0' MIN, 92.0' MAX 0 / u t OAM
0 A LOAMPhone - (508) 420-79M Fax - (508) 420-3919
8'MIN. 3' (min) � 10 YR. 3 j 2 1�`,�p 3 f 2
4' SCED. 40 PVC FIRST 2' (TO BE LEVEL) --- -- --
(TYPICAL) 4' SCED. 40 PVC
6' <ninJ 01:' lnln,
PVC a B MED SAND d SILT LOAM ' �
—
to' /CI ties GAS BAFFLE .sump 4' SCED, 40 PVC JO., 10YR 4/4 40 10YR 4/4 U 0 —0
G'
Finished CONSTRUCT ACCESS / / i
Basement MANHOLE OVER INLET i SCALE IN FEET
NK
Floor =84.25' TO TA TO AT LEAST 12' (ain) Cover, 2'L zyer 1/8'tol/2'VITHIN 6' FINISH GRA Slope = 0,005 (min ) Peo stone C I MED SANID C I M/C SAND
6' CRUSHED y
Reinforced Concret STONE BASE-_
} 36" 2,5Y 714 - 2.5YR 6/6 III
FOOTING T — --- -
C'AC.E. i "=120' DATE: 9- 16-99
4' PERFORATE 2 C2 M C SAND I
SCHEDULE 40 PVC 3/4'to 1 1/2' 2 3, /
Clean washed Stone 7 REV. DATE: REMARKS
2.5Y 6/6 C2 MED- 4-SAND
GALLON SEPTIC TANK DISTRIBUTION BOX C3 M/C SAND 2.5YR 7�2 - - -
1,500 _ I
c 7D BE INSTALLED ON A LEVEL STABLE BASE T 2.5Y 7/2 — -----
TO BE INSTALLED ON A LEVEL STABLE BASE LEACHING TRENCN 5' M,r,
SEPTIC TANK TO BE INSPECTED & CLEANED ANNUALLY 7 OUTLETS REOUIRED -- � Nl1MBER
r undwater Elevation H_A991384—_1�Givil Desi n\ 1384 b.DWG
Adjusted G o
RATE= < 2 MIN/IN —99- 1384—C 1