HomeMy WebLinkAbout0766 ROUTE 149 - Health 766 ROUTE449
MARSTONS MILLS
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` Commonwealth of Massachusetts J�f D
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
�.7
David Thomas c/o Hornbeam_ Trust
Owner Owner's Name
information is ✓ Ma 02648 3/19/17
required for every Marstons mills _ _
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. General Information S
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiB_uono Sewer and Drain _
ab Company Name
Company Address
an n S Yarmouth MA 02664
City/Town State Zip Code
508-364-9587 _ S113522
Telephone Number License Number
B. Certification ;
T
I certify that I have personally inspected the sewage disposal system at this address and thaHhe
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
___ 3/19/17
I 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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 1 of 17
O1Y v
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is required for every Marstons mills Ma C2648 3/19/17
page. City/Town State Zip Code Date of Inspection.
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E /always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System contains a 1,500 Galon septic tank as well as a concrete distribution box and 2 500 Gallon
leaching chambers Heavy water usage noted 628 GPD
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust _
Owner Owner's Name
information is Marstons mills Ma 02648 3/19/17
required for every —
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
766 Rt 149 _
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is Marstons mills _Ma_ 02648 3/19/17
required for every _ _
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust _
Owner Owner's Name
information is required for every Marstons mills Ma 02648 3/19/17
page. City/Town State Zip Code . Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 766 Rt 149 _
Property Address
David Thomas c/o Hornbeam Trust
Owner . Owner's Name - ------ ---- -- ---- ------- --
information is Marstons mills Ma 02648 3/19/17
required for every __-_- _-
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3 —
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 6 of 17
` Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is Marstons mills Ma 02648 3/19/17
required for every --_— __----
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 628 GPD
9 ( Y 9 (gP ))�
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15,203). Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts ti
,mumW Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'c 766 Rt 149 _M
Property Address
David Thomas c/o Hornbeam Trust _
Owner Owner's Name
information is Marstons mills Ma 02648 3/19/17 _required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Annually per home owner
Was system pumped as part of the inspection? ' ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
` Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is required for every Marstons mills Ma 02648 3/19/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2001
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Septic Tank (locate on site plan):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,500
If tank is metal, list age: --
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is required for every Marstons mills Ma 02648 3/19/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness 3�- -- —
"
Distance from top of scum to top of outlet tee or baffle 42 42 —
Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Level in tank is normal. No signs off back up
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
t5ins•3/13 Title 5 Official nspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 766 Rt 149
Property Address
David Thomas c,'o Hornbeam Trust
Owner Owner's Name
information is
required for every Marstons mills — _ Ma 02648 3/19/17
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: —
Capacity: gallons
Design Flow: —
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is required for every Marstons mills Ma 02648 3/19/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Level and at normal level
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.):
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
` Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is
required for every Marstons mills Ma 02648 3/19/17
page. City/Town State. Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Camera inspection to distribution box showed no sins of failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
G'AI
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is required for every Marstons mills Ma 02648 3/19/17
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions - —
Depth of solids —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name
information is required for every Marstons mills Ma 02648 3/19/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f
766 Rt 149
Property Address
David Thomas c/o Hornbeam Trust
Owner Owner's Name a
information is required for every Marstons mills _Ma 02648 3/19/17
page. City/Town State Zip Code 'Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feeetet ft
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: "pate
❑ 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:
Nearest water venue is well below 10 ft
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 16 of 17
'AI�Y ASSESSMENTS
OFFICIAL FORM —NOT I�OIZ VOLUN'I
�
MFS.ULISURFACE SE`4�'AGE DISPOSALSYSTEM INSPIi;C"'T(ON FORM
PART C
61 SYSTEM INFORMATION(continued)
Prop�rfy Address: 766 ROUTE 149 MARSTONS MILLS, MA 02648
f.' wncr: DARREN WILLIAMS
1 r?(eorIrrsprction: 4/0/04
CSC"SEWAGE DISPOSAL SYSTEM
I'rov idc a sketch 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.
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
766 Rt149 _
Property Address
David Thomas co Hornbeam Trust
Owner Owner's Name
information is Marstons mills Ma 02648 3/19/17
required for every — —
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System nformation — Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
PURCHASE AND SALE AGREEMENT
This 1 day of August,2015
1. PARTIES AND Richard Thomas,Trustee of The Hornbeam Trust u/d/t/dated December 15, 1999
MAILING ADDRESSES hereinafter called the SELLER,agrees to SELL and
Andrew Dent and Lacey Dent
hereinafter called the BUYER or PURCHASER,agrees to BUY,upon the terms hereinafter set forth,
the following described premises: 766 Route 149,Marston Mills,MA
2. DESCRIPTION The land with the buildings thereon known and numbered as 766 Route 149,Marston Mills,MA,
County of Barnstable,Commonwealth of Massachusetts and more particularly described by deed
recorded with the Barnstable County Registry of Deeds in Book 22599,Page 147.
3. BUILDINGS, Included in the sale as part of said premises are buildings,structures,and improvements now thereon,
STRUCTURES, and the fixtures belonging to the SELLER and used in connection therewith including,if any,all
IMPROVEMENTS, wall-to-wall carpeting,automatic garage door openers,storm windows and doors,.awnings,shutters,
FIXTURES furnaces,heaters,heating equipment,oil and gas burners and fixtures appurtenant thereto,hot water
heaters,plumbing and bathroom fixtures,garbage disposers,electric and other lighting fixtures,
mantels,outside television antennas,fences,gates,trees,shrubs,plants,kitchen appliances,
washer/dryer,window treatments and blinds,light fixtures,and all shelving in closets and in the
unfinished lower level.
4. TITLE DEED Said premises are to be conveyed by a good and sufficient quitclaim deed running to the BUYER,or
to the nominee designated by the BUYER by written notice to the SELLER at least seven(7)days
before the deed is to be delivered as herein provided,and said deed shall convey a good and clear
record and marketable title thereto,free from encumbrances,except
(a) Provisions of existing building and zoning laws;
(b) Existing rights and obligations in party walls which are not the subject of written agreement;
(c) Such taxes for the then current year as are not due and payable on the date of the delivery of
such deed;
(d) Any liens for municipal betterments;and
(e) Easements,agreements,restrictions and reservations of record.
5. PLANS If said deed refers to a plan necessary to be recorded therewith the SELLER shall deliver such plan
with the deed in form adequate for recording or registration.
6. REGISTERED TITLE In addition to the foregoing,if the title to said premises is registered,said deed shall be in form
sufficient to entitle the BUYER to a Certificate of Title of said premises,and the SELLER shall
deliver with said deed all instruments,if any,necessary to enable the BUYER to obtain such
Certificate of Title.
7. PURCHASE PRICE The agreed purchase price for said premises is$300,000.00
THREE HUNDRED THOUSAND DOLLARS,of which
$ 00.00 have been paid as a deposit this day and
$ 00.00 have been paid to bind the offer
$300,000.00 are to be paid at the time of delivery of the
deed in cash,or by certified,cashier's,
r treasurer's or bank check(s),or attorney IOLTA check
$300,000.00 TOTAL
8. TIME FOR Such deed is to be delivered AT NOON on September 24,2015,at the Barnstable County Registry of
PERFORMANCE; Deeds,unless otherwise agreed upon in writing. It is agreed that time is of the essence of this
DELIVERY OF DEED agreement.
9. POSSESSION AND Full possession of said premises free of all tenants and occupants,except as herein provided,is to be
CONDITION OF delivered at the time of the delivery of the deed,said-premises to be then in the same condition as
PREMISE. they now are,reasonable use and wear thereof excepted. The BUYER shall be entitled personally to
rt�'
inspect said premises prior to the delivery of deed in order to determine whether the condition thereof
complies with the terms of this clause.
10. EXTENSION TO If the seller shall be unable to give title or to make conveyance,or to deliver possession of the
PERFECT TITLE OR premises,all as herein stipulated,or if at the time of the delivery of the deed the premises do not
MAKE PREMISES conform with the provisions hereof,then SELLER shall use reasonable efforts to remove any defects
CONFORM in title,or to deliver possession as provided herein,or to make the said premises conform to the
provisions hereof,as the case may be,in which event the SELLER shall give written notice thereof to
the BUYER at or before the time for performance hereunder,and thereupon the time for performance
hereof shall be extended for a period of up to thirty calendar days. "Reasonable efforts"shall not
require Seller to spend in excess of one thousand dollars including reasonable attorney fees and
otherwise to make the premises comply with the provisions of this Agreement.
11. FAILURE TO PERFECT If at the expiration of the extended time the SELLER shall have failed so to remove any defects in
TITLE OR MAKE title,deliver possession,or make the premises conform,as the case may be,all as herein agreed,or if
PREMISES CONFORM, .any time during the period of this agreement or any extension thereof,the holder of a mortgage on
etc. said premises shall refuse to permit the insurance proceeds,if any,to be used for such purposes,then
any payments made under this agreement shall be forthwith refunded and all other obligations of the
parties hereto shall cease and this agreement shall be void without recourse to the parties hereto.
12. BUYER's ELECTION Excluding amounts recovered or recoverable for personal belongings and appliances,the BUYER
TO ACCEPT TITLE shall have the election,at either the original or any extended time for performance,to accept such
title as the SELLER can deliver to the said premises in their then condition and to pay therefore the
purchase price without deduction,in which case the SELLER shall convey such title,except that in
the event of such conveyance in accord with the provisions of this clause,if the said premises shall
have been damaged by fire or casualty insured against,then the SELLER shall,unless the SELLER
has previously restored the premises to their former condition,either
(a)pay over or assign to the BUYER,on delivery of the deed,all amounts recovered or
recoverable on account of such insurance,less any amounts expended by the SELLER for any
partial restoration,or
(b)if a holder of a mortgage on said premises shall not permit the insurance proceeds or a part
thereof to be used to restore the said premises to their former condition or to be so paid over or
assigned,give the BUYER a credit against the purchase price,on delivery of the deed,equal to
said amounts so recovered or recoverable and retained by the holder of the said mortgage less
any amounts expended by the SELLER for any partial restoration.
13. ACCEPTANCE OF The acceptance of a deed by the BUYER or his nominee as the case may be,shall be deemed to be a
DEED full performance and discharge of every agreement and obligation herein contained,expressed or
implied.
14. USE OF MONEY TO To enable the SELLER to make conveyance as herein provided,the SELLER may,at the time of
CLEAR TITLE delivery of the deed,use the purchase money or any portion thereof to clear the title of any or all
encumbrances or interests,provided that all instruments so procured are recorded with the delivery of
said deed or within a reasonable time after the delivery of the deed in accordance with local
conveyancing practice.
15. INSURANCE Until the delivery of the deed,the SELLER shall maintain insurance on said premises as follows:
Type of Insurance Amount of Coverage
Fire and Extended Coverage As presently insured
16. ADJUSTMENTS Water and sewer use charges,if any,and taxes for the then current fiscal year,shall be apportioned
and fuel value shall be adjusted,as of the day of performance of this agreement and the net amount
thereof shall be added to or deducted from,as the case may be,the purchase price payable by the
BUYER at the time of delivery of the deed. Fuel value shall be adjusted based upon the greater of
price paid by Seller or price at the time of closing.
17. ADJUSTMENT OF If the amount of said taxes is not known at the time of the delivery of the deed,they shall by
UNASSESSED AND apportioned on the basis of the taxes assessed for the preceding fiscal year,with a reapportionment as
ABATED TAXES soon as the new tax rate and valuation can be ascertained;and,if the taxes which are to be
apportioned shall thereafter be reduced by abatement,the amount of such abatement,less the
reasonable cost of obtaining the same,shall be apportioned between the parties,provided that neither
party shall be obligated to institute or prosecute proceedings for an abatement unless herein otherwise
agreed.
b�12 A IJ
18. BROKER's FEE A Broker's fee for professional services per separate agreement is due from the SELLER to N/A,the
Broker(s) herein, to be paid only if, as and when the deed is delivered and recorded and the full
purchase price is paid,and not otherwise.
19. BROKER(S) The Broker(s)named in this Agreement warrant(s)that the Broker(s)is(are)duly licensed as such by
WARRANTY the Commonwealth of Massachusetts.
20. DEPOSIT All deposits made hereunder shall be held in escrow by N/A in a non-interest bearing account as
escrow agent subject to the terms of this agreement and shall be duly accounted for at the time for
performance of this agreement. In the event of any disagreement between the parties,the escrow
agent shall retain all deposits made under this agreement pending written instructions mutually given
by the SELLER and the BUYER or a court of competent jurisdiction.
21. BUYER's DEFAULT; If the BUYER shall fail to fulfill the BUYER's agreements herein,all deposits made hereunder by
DAMAGES the BUYER shall be retained by the SELLER as liquidated damages and this shall be Seller's sole
and exclusive remedy at law or in equity.The parties acknowledge that in the event of any default by
the Buyer under this agreement,Seller's damages would be difficult or impossible to compute and
that the earnest money represents a reasonable estimate of such damages as established by the parties
through good faith consideration of the facts and circumstances surrounding the transaction
contemplated under the agreement as of the date hereof.
22. RELEASE BY The SELLER's spouse hereby agrees to join in said deed and to release.and convey all statutory and
HUSBAND OR WIFE other rights and interests in said premises.
23. BROKER AS PARTY The Broker(s)named herein join(s)in this agreement and become(s)a party hereto,insofar as any
provisions of this agreement expressly apply to the Broker(s),and to any amendments or
modification of such provisions to which the Broker(s)agree(s)in writing.
24. LIABILITY OF If the SELLER or BUYER executes this agreement in a representative or fiduciary capacity,only the
TRUSTEE, principal or the estate represented shall be bound,and neither the SELLER or BUYER so executing,
SHAREHOLDER, nor any shareholder or beneficiary of any trust,shall be personally liable for any obligation,express
BENEFICIARY,etc. or implied,hereunder.
25. WARRANTIES AND The BUYER acknowledges that the BUYER has not been influenced to enter into this transaction nor
REPRESENTATIONS has he relied upon an warranties or representations not set forth or incorporated in this agreement or
previously made in writing,except for the following additional warranties and representations,if any,
made by either the SELLER or the Broker(s):none.
Seller shall not be liable or bound in any way for any verbal or written statements,representations,or
information pertaining to the premises finished by any real estate broker or agent or any agent or
employee of Seller,or any other person. It is understood and agreed that all prior and
contemporaneous representations,statements,understandings,and agreements,oral or written,
between the parties are merged in this Agreement,which alone fully and completely expresses their
agreement,and that the same is entered into after full investigation,neither party relying on any
statement or representation not embodied in this Agreement made by the other. The acceptance of
the Deed by Buyer on the Closing Date shall be deemed full performance and discharge of each and
every agreement and obligation on the part-of the Seller hereunder to be performed. Any and all
representations and warranties of Seller contained in this Agreement shall not survive the recording
of the deed.
26.MORTGAGE In order to help finance the acquisition of said premises,the buyer shall apply for a conventional
CONTINGENCY bank loan or other institutional mortgage loan of$$294,566 at prevailing rates,terms and .
conditions. If despite the Buyer's diligent efforts a commitment for such loan cannot be obtained on
or before September 22,2015,the Buyer may terminate this agreement by written notice to the Seller,
prior to the expiration of such time,whereupon any payments made under this agreement shall be
forthwith refunded and all other obligations of the parties thereto shall cease and this agreement shall
be void without recourse to the parties hereto. In no event will the BUYER be deemed to have used
diligent efforts to obtain such commitment unless the BUYER submits a complete mortgage loan
application conforming to the foregoing provisions on or before the date of this agreement. In the
event of a mortgage denial,Buyer shall provide Seller with a copy of same.
27.CONSTRUCTION OF This instrument,executed in multiple counterparts,is to be construed as a Massachusetts contract,is
AGREEMENT to take effect as a sealed instrument,sets forth the entire contract between the parties,is binding upon
and inures to the benefit of the parties hereto and their respective heirs,devisees,executors,
administrators,successors and assigns,and may be cancelled,modified or amended only by a written
r
instrument executed by both the SELLER and the BUYER or their respective attorneys. If two or
more persons are named herein as BUYER their obligations here under shall be joint and several.
The captions and marginal notes are used only as a matter of convenience and are not to be
considered a part of this agreement or to be used in determining the intent of the parties to it.
28. LEAD PAINT LAW The parties acknowledge that,under Massachusetts law,whenever a child or children under six years
of age resides in any residential premises in which any paint,plaster or other accessible material
contains dangerous levels of lead,the owner of said premises must remove or cover said paint,plaster
or other material so as to make it inaccessible to children under six years of age.
29.SMOKE AND CARBON The SELLER shall,at the time of the delivery of the deed,deliver a certificate from the fire
MONOXIDE department of the city or town in which said premises are located stating that said premises have been
DETECTORS equipped with approved smoke detectors and carbon monoxide detectors in conformity with
applicable law.
30. ADDITIONAL
PROVISIONS
SELLER'S PERFORMANCE IS CONDITIONED UPON SELLER SECURING SUITABLE HOUSING
FOR RESIDENTIAL PROPERTY CONSTRUCTED PRIOR TO 1978,BUYER MUST ALSO HAVE
SIGNED LEAD PAINT"PROPERTY TRANSFER NOTIFICATION CERTIFICATION"
NOTICE: This is a legal document that creates binding obligations. If not understood,cons It an attorney.
T L r
Q� 0f (ICrn�oc,,, I ns
L i SEL ER:
U�t
BUYER: ,R:
Broker(s)
Wt '
- COMMONWEALTH OF MASSACHUSETI`S
r
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
t d DEPARTMENT OF ENVIRONMENTAL PROTECTION
S%b
a
gas
TITLE 5
OFFICIAL INSPECTION FOIL—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Progeny Address: (D
Gpr o
Owner's Name: J O.SG �h S
Owner's Address: 6 n 4 9 / OV
Date of Inspection: 10- 1>
Name of Inspector: please print) Zell
Q✓K '
Company Name: 1�1 0 7—E-G
Mailing Address: C> b $
as ti Od=6�El
Telephone Number:�V—F P7S
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infoi3nation reported .
below is true,accurate and complete as of the time of the inspection.The inspection was performed�ased one C7
training and experience in the proper function and maintenance of on site sewage disposal systems.I?. m a DEP
approved system inspector pursuant to S on.15340 of Title 5(310 CMR 15.000). The s
t
Conditionally Passes
Needs Further Evaluation by the Local Approving Autho
Fails
i
� r'
Inspector's Signature: 2T, i Dale: /a2
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �v�/ / Z 7'
�v ,4 r
Owner: 'of �s.
Date of Inspection: / d
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sy ern Passes:
I have not found any information which indicates that any of the failure criteria described in 310 C-M R
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. Sy tem 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.
Answer yes,no or not determined(Y,N,ND)in the 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 wall 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.
ND explain:
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
obstruction is removed
distribuiiort box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL. INSPECTION FORK[-NOT FOR VOLUNTARY ASSESSMWI TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION)F'ORIM
PART A
CERTIFICATION(continu
ed)
ed
Property Address: _
Owner:
Date of Inspection: Q
C.,y Further Evaluation is Required by the Board of Health:
// Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMI215303(1)(b)that the
system is 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 marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic conTounds 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
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS1iENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection: !a p
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
dogged SAS or cesspool
/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
.esspool
Z iquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
,of times pumped
y 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.
y portion of a cesspool or privy is within a Zone 1 of a public well.
_ _ 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 coliform bacteria and 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.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CNIR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
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)
X
the system is within 400 feet of a surface drinldng water supply
the system is within 200 feet of a tributary to a surface drinldng water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 C_NIR
15.304.The system owner should contact the appropriate regional office of the Department.
-- - -- - - _.. -- - - - A
Page 5 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE FACE SEWAGE DISPOSAL SYSTEM INSP>CCTTON FORM
PART B
CHECKLIST
Property Address:
Owner: ��S —l ✓f," s��� O�L�f
Date of Inspection: /� Q
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes �o
f/ _ P ing information was provided by the owner,occupant,or Board of Health
_ �an of the system components ed out in the e y y mpo pump previous two weeks
v Has e system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
7Was
es or tees,.material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
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:
Yes no
/ 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(3)(b)]
Page 6 of I I
OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM
YSTE/M/INFORMATION
Property Address:
Owner:
Date of Inspection: d 9
RESIDENTIAL
FLOW CONDITIONS
�lM
Number of bedrooms(design): —�> Number of bedrooms(actual): Cl?0 0/
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage systems or no /j/,O[if yes separate inspection required;
Laundry system inspected(y �r no): (�
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): /L'o
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records // /
Source of inforation: ��T
m A! of c� j+— --- 0 L— ,
Was system pumped as part of the inspection(yes or no): XV
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
GYPS®F 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)
_Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components d to installed(if known)and source of ormation:
��+1✓ 1 — ✓ S, pZp 0 f.
Were sewage odors detected when arriving at the site(yes or no):/ /v
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISP®SAL SYSTEM INSPECTION FORM
PART C
/`� SYSTEM FORMATION(continued)
Property Address: /6V a I—
/�
Owner:
Date of Inspection: b 0
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _ PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
� a
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction: oncrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: S
Sludge depth: n
Distance from top of sludge to bottom of outlet tee or baffle: c2 9
Scum thickness: 1 d_`�
Distance from top of scum to top of outlet tee or baffle: 6 ��
Distance from bottom of scum to bottom of outlet tee or.bape: /
How were dimensions determined: o le /C'A c��yi c _
Comments(on pumping recommendations,inlet and outlet fee or baffle condition,structural integrity,liquid levels
as related to putlet vert,evidence of leakage,etc. : / /
le 7— �/c � 6 e �dr oo C o-d�✓. �`(e
c�. jo
ple/L ':qoo H j.
GREASE TRAP:/l/ locate on siteplan) ~
—(
Depth below grade:
Material of construction:_concrete-_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, hcp levels
as related to outlet invert,evidence of leakage,etc.):
1
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORIM
PART C
SYSTEM INFORMATION(continued)
Property Address:
��? OOLC 4-2--7
Owner: w-
Date of Inspection: 14A>A0
TIGHT or HOLDING TANK: It' (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: if resent must be o ene ocate o( p p d)(1 n site plan)
Depth of liquid level above outlet invert: k1Q1V-7,riZ—
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.):
,cam��e
PUMP CHAMBER:zvoocate on site plan)'
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMMi NITS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION )FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: (� /�"
/W 0--64511-
Owner: n
Date of Inspection: �� 7 D
SOIL ABSORPTION SYSTEM(SAS): y (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number: CC:2)
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): Cj — /'2-e.
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:k(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.):
r
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: / ? 6
SKETCH OF SEWAGE DISPOSAL,SYSTEM
Provide a sketch 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 buildin
ii
1
/ Vd
/ s .41 r
�i d-I
,rl.
l
r[ai_ c T___,_a__� T_�__ rlicrnnnn to
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
O / SYSTEM INFORMATION(continued)
Property Address:— / p �/ _zf/
Owner• DOS l
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar �-
Shallow wells
`^ r
W /
Estimated depth to ground water feet
4 w
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
O ed site(abutting property/observation hole vn�'fjn 50 feet o SA )
ecked with local Board of Health-explain: lam_
Checked with local excavators,installers-(attach documentation) ;
Accessed USGS database-explain:
You must scribe hoJw ou stablished the hi hJvound wjter ele afion:
/ v� t 'Xz t-,
Al
I
Town of Barnstable
�p THE Tp�
Regulatory Services
snxxsrnsie Thomas F. Geiler, Director
ArEo3rA Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
r
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed.within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
F
ECEn1rrAY 2 9 2001 OF EiArcivJ i AdI E
TITLE 5 EALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 766 R t. 1 4 9
Marstons Mills, MA
Owner's Name: John Eggert
Owner's Address: �amP
Date of Inspection: i %d C2 I
Name of Inspector: (please print) Wi 1 1 i am E_ . Rob i_nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5-8 7 7.6
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 15340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
lFails
Inspector's Signature: ��� I ,/� Date: - 9 -0 �
e system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea&,or
D )within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gp or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DE .The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing
auth rity.
Not s and Comments
Xs�w -S ,d s s,—� I..-0 9
* *This report only describes conditions at the time of inspection and under the conditions of use at that
ti e.This inspection does not address how the system will perform in the future under the same or different
c nditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
,,,•,e-g.- PART A
CERTIFICATION(continued)
Property Address: . 766 Rt. 149
Marstons Mills
Owner: "N Eggert
Date of Inspection: .5'
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I.have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
� L; KJ
System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
re aired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
swer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
ex lain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
ound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
e sting tank is replaced with a complying septic tank as approved by the Board of Health.
* metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
dicating that the tank is less than 20 years old is available.
D explain:
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
obstruction is removed
distribution box is leveled or replaced
explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pa inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
explain:
�_ J
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 766 Rt. 1 4 9
Marstons Mills
Owner: Eggert
Date of Inspection:
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 fa ling to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ 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 any)determines that the.
sy tem 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 front a
private water supply well**.Method used to determine distance
*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ailure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
g ,.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:766 R t. 1 4 9
Marstons Mills
Owner: Eggert
Date of Inspection:
System Failure Criteria applicable to all systems:.
Y u must indicate"yes"or"no"to each of the following for all inspections:
Ye No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of 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 l of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and 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.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. L rge Systems:
To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd-
You ust indicate either"yes"or"no"to each of the following:
(Th following criteria apply to large systems in addition to the criteria above)
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 drinldng water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well .
If ou have answered"yes"to any question in Settinn E the system is considered a significant threat,or answered
"y s"in Section D above the large system has famed.The owner or operator of any large system considered a
si nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15 04.The system owner should contact the appropriate regional office of the Department.
4
1
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 6 6 Rt. 1 4 9
Marstons Mills
Owner: Eggert
Date of Inspection:L/`/—a I
Check if the following have been done You must indicate`yes"or"no"as to each of the following:
Yes /No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
t/ 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?
t� 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:
Yes no
Existing information.For example,a plan at the Board of Health.
v 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)]
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 766 Rt. 1 4 9
Marstons Mills
Owner: Eggert
Date of Inspection: S—✓G/"6
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):„7 Number of bedrooms(actual): .�i
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:__�I_
Does residence have a garbage grinder(yes or no): /L a
Is laundry on a separate sewage system(yes or no):/f,,6 [if yes separate inspection required]
Laundry system inspected(yes or no):AL.o
Seasonal use:(yes or no): A c
Water meter readings,if available(last 2 years usage(gpd)): 2000 102,000 gal.
Sump pump(yes or no):_20 1999 111 , 000 gal.
Last date of occupancy:. '
C MERCIAL/INDUSTRIAL
Type f establishment:
Desig flow(based on 310 CMR 15.203): gpd
Basis f design flow(seats/persons/sgft,etc.):
Gre a trap present(yes or no):
Indu trial waste holding tank present(yes or no):_
Non sanitary waste discharged to the Title 5 system(yes or no):_
Wa er meter readings,if available:
L ate of occupancy/use:
OT ER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: •rim
Was.system pumped as part of the inspection(yes or no): c1
If yes,volume pumped: ZLoLgallons--,,Now was quantity pumped determined?
Reason for pumping:
TYPOF 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)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): d
6
Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address?6 6 Rt. 1 4 9
Marstons Mills
Owner: Eagert
Date of Inspection:
BUI ING SEWER(locate on site plan)
Depth b low grade:
Material of construction:_cast iron _40 PVC_other(explain):
Distance om private water supply well or suction line:
Comme s(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Z(locate on site plan)
Depth below grade: �
Material of construction:✓oncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: ZI q
Scum thickness: -0— , t
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:t k
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.):
G ASE TRAP:_(locate on site plan)
Dep below grade:
Mate al of construction:_concrete_metal_fiberglass_polyethylene_other
(expl in):
Dime sions:
Scu thickness:
Dis ce from top of scum to top of outlet tee or baffle:
Dis nce from bottom of scum to bottom of outlet tee or baffle:
Dat of last pumping:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as lated to outlet invert,evidence of leakage,etc.):
7
Pag e8ofll '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 766 Rt. 149
Marstons Mills
Owner: Eggert
Date of Inspection:
TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth I grade:
Materia of construction: concrete metal fiberglass_polyethylene other(explain):
Dimens ons:
Capaci gallons
Design low: gallons/day
Alarm p esent(yes or no):
Alarm I vel: Alarm in working order(yes or no):
Date of ast pumping:
Comm nts(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: /of present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: d
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.):
PU P CHAMBER: (locate on site plan)
Pu ps in working order(yes or no):
Al s in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
1 -
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress-Y66 Rt. 149
Mars tons Mills
Owner: Eggerrt
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): �/(locate on site plan,excavation not required)
If SAS not located explain why:
Type
1',aching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): J
CESSPOOLS: (cesspool must be pumped
/as part of inspection)(locate on site plan)
Number and configuration: ry
g
Depth—top of liquid to inlet in eft:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR (locate on site plan)
Materi is of construction:
Dime ions:
Dep of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 766 Rt. 1 4 9
Mars ons Mi 1 Lg
Owner: E
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
r
Y
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address)6 6 Rt- 1 4 9
Marstons Mills
Owner. Eggert
Date of Inspection: 5 a
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
¢bserved 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:
r b
11
0iv�
COMMONWEALTH OF MASSACHUSETTS 1�71010
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
F DEPARTMENT OF ENVIRONMENTAL PROTECTION RE = :'
M
' RECEIVED
,o^M SYe.� �l�AP
APR 2 8 2004 PARCEL 0�
{{ F BARNSTABLE LOT
T H DEPT. '
OFFICIAL INSPECTION FORM— OT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A ,
CERTIFICATION
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner's Name: DARREN WILLIAMS
Owner's Address: 766 ROUTE 149 MARSTONS MILLS,MA.02648
Date of Inspection: 4/6/04
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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
_ Conditional sses
_ Needs Furt valuation by the Local Approving Authority
Fails
Inspector's Signature: Date: 4/6/04
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti n.If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner sh 11 submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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.
Titles 5 Tncnpr.tinn Fnrm 611 V?000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
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
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
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.
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
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.
ND explain: n/a
n/a 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
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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
_obstruction is removed
ND explain: n/a
Page 3 of 11
r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ 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 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and
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.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
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 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
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 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ 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 passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and 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,iprovided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
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 water supply
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
n
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
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
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)
X _ Was the facility or dwelling inspected for signs of sewage back up
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS, located on site
X _ 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
X _ 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:
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)]
S
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
FLOW CONDITIONS
RESIDENTIAL
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: 4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
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 Z Gg)C\A0
Sump pump(yes or no): NO
Last date of occupancy: n/a v 3 �O
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
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): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
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
Reason for pumping: n/a
TYPE OF SYSTEM
X 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
12 YEARS PER OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I 1
y
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
BUILDING SEWER(locate on site plan)
Depth below grade:30"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:24"
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: L 8' 6" H 5' 7" W 4' 10"
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle:33"
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
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
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
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
7
I
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
LEACHING CHAMBERS leaching chambers, number: 2
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
CHAMBERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS
OF FAILURE.PIT WAS EMPTY AT TIME OF INSPECTION.THERE ARE NO STAIN LINES,INDICATING PIT
HAS NEVER HAD ANY LIQUID IN IT.BOTTOM IS AT 6 FT.
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
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
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
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
VV
o �
PC,
�ZS
6b-P
in
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 766 ROUTE 149 MARSTONS MILLS,MA 02648
Owner: DARREN WILLIAMS
Date of Inspection: 4/6/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12 FT.
11
h
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in
town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town
Clerk's Office, 1' FL., 367 Main Street, Hyannis, MA 02601 To n Hall) and 200 Main Street Offices at the Licensing counter.
DATE:
" Fill in please:
APPLICANT'S YOUR NAME: Ajr t
BLI IE S YOUR HOME ADD ESS:
Mo � 5 Ogg
TELEPHONE # Home Telephone Number: �()
NAME OF NEW BUSINESS RES 414 I I&I—ed" TYPE OF BUSINESS ro u
IS THIS A HOME OCCUPATION? YES NO
Have you been given approv I fir �theJuVing division? YES NO
ADDRESS OF BUSINESS �� V.1, 9 1 MAP/PARCEL NUMBER
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of
the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200
Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally
operate your business in this town.
1 . BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements�that pertain to this type of business.
Authorized Signature
COMMENTS:
2. BOARD OF HEALTH
This individual hasrbee.n info med of he pe it re ments that pertain to this type of business.
Authorized Signature
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
l/
161
RIM V19
/9�
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508-428-8926 FAX: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
-7 6 6 CERTIFICATION,
Property Address: �6311_4_ 1�.
Date of Inspection:_/D-,.:?_9(.-) Inspector's Name:
Owner's Name and Address:
CERTIFICATION STATEMENT*
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the.time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal pstems. The System:
Passes
Conditionally Passes
Needs Further Ev tion By the71L, cal Aproving Authority
Fails _
Inspector's Signature: V Date:—
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY
A)SYSTEA PASSES:
✓ I have not found any information which indicates that the system violates any of the failure
criteria as defined 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 comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,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
exfrltration,or tank failure is imnunent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
_ 1 _
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed.
Distribution Box is levelled or replaced
The System required pumping more than four times a year.due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced _ Y
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF IIEALTH:
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 IIEALT11 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 FUNCTION-
ING 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 1O0 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I 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 and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrnte nitrogen is equal to or less
than 5 ppm.
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 into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than G°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). Number of times pumped
-2-
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
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 I 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 a large system in addition to the criteria above:
The design flow of a system is 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
r .
CHECKLIST
Check Pe following have been done:
1/Pumping information was requested of the owner,occupant,and Board of Health.
✓None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
V'As-built plans have been obtained and examined. Note if they are not available with N/A.
VThe facility or dwelling was inspected for signs of sewage back-up.
t/The system does not receive non-sanitary or industrial waste flow.
--,Zile site was inspected for signs of breakout.
V/All system components,excluding the Soil Absorption System,have been located on site.
✓The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of bales or tees,material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
V 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.
4 `t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
__L_^e facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System (�
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
/ FLOW CONDITIONS
RF.SMENTIA_L:_
Design Flow: allons Number of Bedrooms: Nu�n�bber�C�o.�>>f Current Residents:
Garbage Grinder. Laundry Connected To System:�7 c v Seasonal Use: U
Water Meter Readings, if ilable:
Last Date of Occupancy: 6_"/ C 9 55 ce
a�
CO MER LAIANDLISTRiAi o
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present: i
Non-Sanitary Waste Discharged To The Title V System:
Water.Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of inform ion: rVA0 Ct �
System Pumped as part of inspection: If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM:
V Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
M
O TE AGE of all co �nen �Iestalled(if known)and source of. information:
Sewage odors deter hen arrivinC1G
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK.-
Depth below grade: Material of Construction: ✓concrete metal FRP Other
(explain)
Dimisions X Sludge Depth: 4 _Scum ThWess: /U
ff1 Distance from top of sludge to bottom of outlet tee or ba e: 3 3
Distance from bottom of scum to bottom of outlet tee or baffle: ti
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level i lation outlet invert,structural integrity,evidence of leak ge,etc.�s a /o? 7� //X
v
it
v
GREASE TRAP:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
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.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction: concrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: o(' /,?W/
Comments: (note' level and di trib don is, al,evi ence of soli s carryov r,evidence of 1 ge into
or out of box,etc. (
n
PUMP CHAMBER:—A-6
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
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:
Type: ,
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil, igns of hydraulic failure level of g,condition of vegetation,,
it
e
CESSPOOLS:
Number and con Aation: 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(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY,
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include des to adeast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
/V� O
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet �`l�
Method of Detemun lion or pro 'madon: 7�^��'1 �t r
�® 1
-7-
TOWN OF BARNSTABLE
i LOCATION ;� � �' SEWAGE #12
`iILLAGE ,G-"i dl/,�'d J 1 a: ASSESSOR'S MAP & LOT
INSTALLER'S NAME&IPHONE NO. �� .c �. �'°,
SEPTIC TANK CAPACITY 296
LEACHING FACILITY: type). — (size)
NO.OF BEDROOMS ,✓� +�
BUILDER OR OWNER Al
PERMITDATE: ��f` 6 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leac21sexist
Facility Feet
Private Water Supply Welland Leaching Facility (If any
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
- a
t
z-.,,
TOWN OF BARNSTABLE
LOCATION Co . P / SEWAGE#
VILLAGEEr�s'ECOIeU /✓�G. S ESS S MAP
&L T/4��'
O R `,:NAME&PHONE N
SEPTIC JTANK CAPACITY
LEACHING FACILITY: (type) / (size) 0 ,
NO.OF BEDROOMS /
BUILDER OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (ff 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 l�"�`" �o
.: '�
�" �'� _;
�� a
�� i�
6'
� �
1 � � o . ..
�/
s TOWN OF B.ARNSTABLE AzIZ,6, P F"
LOCATION C(}(� 1� � i SEWAGE #
VILLAG vn ASSESSOR'S MAP & LOTS
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) // (size)
c"00
NO. OF'BEDROOMS PRIVATE WELL OR t BLIC WATER)
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED: -
VARIANCE GRANTED: Yes No
co -go--a
Or
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v
3u' Z
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w.. r
No.�. �d i i t � Fe$5
— -----THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Mizpomt *pztem Conztruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) El Complete System El Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
766 Rt. 149, Marstons Mills John Eggert
Assessor's Map/Parcely✓t� � 2 ry
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P O Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 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 Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting
of a D-box and 2 concrete leach chambers with stone all
around.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this ELQar f Health
Signed 1 Date '��11 r
Application Approved by Date�
Application Disapproved for the following reasons
Permit No. d� Date Issued
No.0?7J���" t7 Fee$50.
— Entered in computer: V
� --------THE COMMONWEALTH OF MASSACHUSETTS
Yes
PUBLIC HEALTH,DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pplication for Mitpool *pztem Conaruction Permit
w�
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. t`
1766 Rt. 149., ,Marstons Mills John Eggert
'Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. 1 . Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 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 Sand
Nat of Repairs or Alterations(Answer when applicable) Title-5 leach system consistio�g
o`f a D-box and 2 concrete leach cam ers with stone all
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
` in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been 11 issued by this
ar of Hlt . _
Signed Date Il V J
Application Approved by Date:2�-"��"21p `
Application Disapproved for the following reasons
i
Permit No. A;2- Date Issued '
-- --------C---------------------------
THE COMMONWEALTH OF MASSACHUSETTS
i BARNSTABLE, MASSACHUSETTS
Eggert 7.o'U I -Z 7�/3
Certif irate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( )
Abandoned( )by Wm./ E. Robinson Septic Service
at766 Rt. 149, Marstons Mills has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Perini. ate
Installer Wm. E. Robinson Sr. Designer
The issuance of this perpuit shall not be construed as a guarantee that the sy,�t�} will f�u�pcti. s desi
Date 1q Inspector �'�/0.�t ��
----y---a—�-------------------------------
No. / Fee 5 0
�r THE-COMMONWEALTH,OF MASSACHUSETTS a
PUBLIC HEALTH`DIVISION -`BARNSTABLES MASSACHUSETTS
Eggert lwizpozal bpotem Congtruction Permit
Permission is hereby ranted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 166 Rt. 149, Marstons Mills
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of :' permit.
Datef PProve2�'`� S� A y 4
1/6194
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
C-nrr iCA'nON OF SKETCH AND APPLICATION FOR A m9wWAL
WORKS_CONS RUMON PER 1 ONTM UT DUMNED PLANS)
Will iatn E_ Robinson,S y cerffY d=the apphaltion fir dkVoW works
coon permi[igned by me dated , concerning the
prop" located at 766 Rt. 149, Mars tons Mills meets all of the
fouowing criteria:
• The failed system is connecmd to a mideatial dwelling o*, These arc no commercial or business
uses associated with the g
• The soil is ctassi5od as I and the perculation tate is less than or equal to 5 minums per inch
There arc no wetlands 100 feet of the pmposed scW k3's[em —
There arc no private within 150 feet of the propowd septa:gstcu
- There is no in ftm acid or cbangt in me pwpostd
• Thme are no aegtttsted or neoded.
• The bonam of W%med leadmig hdW ww nw_be loci Im than five Cm above the
maamum ed gwitndwater table elevation:JAdjust the gmundimer table using the Frimptor
mctbod w applic"I
• If the S_will be k=icd with 250 boa of any vegetated walands~the bottom of the pmposed
I eaching fact"UtS►wt7l w be located less than%un=114)feet above the maxinwm adjusted
gwuxzdtvawr table elcratiM
Pkase compku the So ewiW
A) Top ofGamad So3*=Ekvafan Curing GIS inSKMaow]
B 1 G.W.Elevation +d t MAX ftb G W as tsst mm
DIFFERENCE BETWEEN A and Fs
SIGNED:- DATE:
(Ske"Pad llall as sysem on b wkl.
.,:a=un row cm
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