HomeMy WebLinkAbout0185 SANDY VALLEY ROAD - Health 185 SANDY VALLEY R0 _
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cam, Commonwealth of Massachusetts '
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Sandy Valley Rd. L,
Property Address
Chance Pagani
Owner Owner's Name
information is Marstons Mills MA 02648 8/14/2019
required for every '
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer, Douglas Brown
use only the tab g
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services Inc.
use the return Company Name
key. 350 Main Company
ray Company Address
West Yarmouth MA 02673
ClWown State Zip Code
508-775-2825 S14297
Telephone Number License Number
B. Certification cation
I certify that: I am a DEP approved system inspector In full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on;-site sewage disposal systems. After conducting this inspection I have determined
that the system: t
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
1 _--- 8/27/2019
Ins or's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
In the future under the same or different conditions of use.
l5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•� 185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is Marstons Mills
required for every MA 02648 8/14/2019
page. Cltylrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 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 in working condition.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
.Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System Page 2 of 18
Commonwealth of Massachusetts
Z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments s
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is Marstons Mills
required for every MA 02648 8/14/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is Marstons Mills
required for every MA 02648 8/14/2019
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the.system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or."No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
F�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 8/14/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y 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 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is every Marstons Mills
required for eve MA 02648 8/14/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® 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)]
t5insp.doc rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information
equir for
is every Marstons Mills
required for eve MA 02648 8/14/2019
page. City(rown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110,gpd x#of bedrooms): 110x2=
Description: 220gpd
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available usage last 2 ears 2017=123gpd
( y g (gpd))' 2018=93gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
t6insp.doc•rev.7/26/21118 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is
required for every MarstonS Mills MA 02648 8/14/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NO Records
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
required for
is every Marstons Mills
required for eve MA 02648 8/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records if an
p � Y)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Est.20
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 28"feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: +10,
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line was checked with sewer camera and found to be clean, properly pitched with no sign of root
intrusion.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is
required or every
very Marstons Mills
MA 02648 8/14/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
6. Septic Tank(locate on site plan):
I'
Depth below grade: 16"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions: 1500Gal
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers
14" below grade.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is required for every Marstons Mills MA 02648 8/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y
185 Sand Valley Rd.
-�
Property Address
Chance Pagani
Owner Owner's Name
required for
is every Marstons Mills
required for eve MA 02648 8/14/2019
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids
carryover. No sign of overloading or hydraulic failure. Cover 20" below grade.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
lip Title 5 Official Inspection Form
F1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owners Name
information ati is every
Marstons Mills
required for eve MA 02648 8/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1-6x6
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:.
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�u
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is required for every Marstons Mills MA 02648 8/14/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1-6x6 Pit with stone. 2' of effluent in pit at time of inspection. No evident stain above current level. No
sign of overloading or hydraulic failure. Cover 28" below grade.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
R Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is required for every Marstons Mills MA 02648 8/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� � 185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information is required for every Marstons Mills MA 02648 8/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18
L
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
required for
is every Marstons Mills
required for eve MA 02648 8/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: +14'
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand auger did not encounter water at 14'. Bottom of leaching is 9'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
- 0s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•, � 185 Sandy Valley Rd.
Property Address
Chance Pagani
Owner Owner's Name
information
equired fo is every Marstons Mills
required for eve MA 02648 8/14/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
f
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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SEPTIC TANK CAPACITY `00
LEACHING FACILrrY:(type J (sue)
NO.OFBEDR00
BUILDER OR WNE
PERMITDATE: COMPLIANCE ATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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Property Address 7ScIn
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required for every
page. CAy/Town State Zip Code Date of nsp coon�aa
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.
Irn portant:When A. General Information
fining out forms
on the only
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Company Name
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Telephone Numb l License Number
B. Certification
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�10CM15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3 /
Inspector s Sgnature Gate
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 goo 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 tc 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.
t5iro,3/13 Titre solriaai impecumrorm.Subeurfeee SewageOisposei System-Page 1 of 17
I
6A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
✓ d C, y
Property Address
Cw ner oar ner's Name
information is r j/��
required for every
page. Qylrown State Zip Code Date of Ins ction
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ always com plete all of Section D
A) System P ses:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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 ex.Oain.
5
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 existinb 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):
t9ns•3113 Title 5 Official Ins pection F orm Subsurface Savage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l �S a�C vl;� Ile �
Property Address
Owner Ow ner's Name
information is /�/
required for every
page. Cityfrown State Zip Code Date of insi6ectiolli
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 mannerwhich 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
t5ns•3M3 Title50tficialInspecticnFomc Subsurface Sewage Disposal System-Page3of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25�5 P� i/�
Property Address
-7-1S�G�
D'"ner Ow ner's Name l
information is Ae,,rS'-4,,175 /" " 'l I �� od`b
required for every
page. Cityfrown State Zip Code Date of Inspect
B. Certification (cost.)
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
�ctogged SAS or cesspool
❑ E1, Discharge or ponding of effluent to the surface of the ground or surface waters
_--due to an overloaded or clogged SAS or cesspool
❑ ET' Static liquid le%el in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
tans•W13 Tise 5 Official Ina pecaon F orrrr Subsu lace Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal system Form -Not for Voluntary Assessments
z25 SG c/tj Ae A't)
Property Address ,
✓ �cS ti lPi
inf ner Owner's Name// 4 //S �j /
information is / Y/ v�k.gs
required for every �rS HJ
page. Cityrrown State Zip Code Date of InsL,-?Z!k
ecti n
B. Certification (cont.)
Yes
ElNo Required pumping more than 4 times in the last year NOT due to clogged or
structed 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.
❑ L� Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 9' Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Lam' 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-
0 00 Og pd.
❑ 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.
t5irs•Y13 Title5 Official Impec bon Form Subsurface Sewage Disposal System-Page 5of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
192,5 VGh klG / /
Property Address % � C74-
-
ner oNner's Name
inf /��/s /�,(/* �information is /170zrz�40-5
required for every
page. City frown State Zip Code Date of lospegkion
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes o
❑ mping information was provided by the owner, occupant, or Board of Health
;I--
Were any of the system components pumped out in the previous two weeks?
❑ as 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 NIA)
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?
�Eol 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): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x #of bedrooms):
t5ns-3113 Title 5 official Inspection F orm Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l �J� Sao C] tzg Ile
Property Address
Cw ner Ow ner's Name
/l
information is v / aJ 4(4y l /
required for every
page. 5 crown State Zip Code Date of Inspec ion
D. System Information
Description: / /00 b
�S�//S w77o•-r
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Ems— o
information in this report.)
Laundry system inspected? ❑ Yes D—fgm
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes KKNo
(�'_url:e
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 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:
�rns-V1 3 Title$Official Its pec Son F orm Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not ffor Voluntary Assessments —I
Property Address
ON ner Ow ner's Name
information is �,5�N s "M'
required for every —
page. Citylrown State Zip Code Date of lr4pecti6n
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
00
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumpin
Type Of em:
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 VA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (descd be):
t5ns•3113 Title 5 Official ins pectlon Form Subsu face Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r• SG,�� "/,e C7
Property Address /
CSC a I
Oav ner Ory ner's Name
information is rs J 11/f ,// O'� 4
required for every
page. City/Town State Zip Code Date of Insp ctio
D. System Information (cont.)
Approximate age of all components, date installed if known) and so a information:
O �
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Dept h bel ow g ra de: feet
Material of constructi:�40
El cast iron 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):
Depth below grade:
P 9 feet
Material of c uction:
oncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ns•3113 Title5 Official lnspeclionFam Subsu-face Sewage Disposal System-Page gof17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
pr / g`j sAr I
Property Address �✓
Isla I
Ow nerrm Oav ner's Name information 7'�� /''/'/lS b U
information is
required for every
page. City/town State Zip Code Date of In pectin
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
i
Distance from bottom of scum to bottom of outlet tee or baffle
�
How were dimensions determined? /c � .
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
//o Z-f
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
15irs•3113 Title50tficlal IrspecfionForm Subsrfam Sewage Disposal System•Page 10d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage
QQ SCP7C/C-jDisposaI System Form -Not for Voluntary Assessments
"r / US !�ar g Ae
Property Address / J /
a
Q nerorrn onrner's Name �,� /
re required
is ads .i/f / 9l 0�6
required for every State Zip Code Date of Inspectio
page. City/Town
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
t5ms•N13 TiU50fficial ins pec bon Form:Subsurface Sewage Disposal system•Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/lam r�
Property Address
Owner Owner's Name $ s __U /4 7 // Ll__X?
�'
information is b
required for every State Zip Code Date of Ins pe lion
page Cityfrow n
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Fee
Q�
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):
9 SAS not located, explain why:
t51ns 3113 Tide501flcial InspectionFomc Subsulace Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
• Form
Title 5 Official Inspection Fo
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address ! /
<s a
na ON Name inf I ///I/ r /� )
information is a/S �f /I` OO�(CSC�
required for every State Zip Code Date of Inspe tlon
page. Cityfrown
D. System Information (cont.)
Type: / -
's
leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
—707—07 t- 0 Z/
I ro *lc",
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
t5lre•3113 Title 501ficial inspecton F crm:Subsurface Sewage Disposal System•Page 13 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
d(,7 - k-.1
Property Address
Ts�p
Ow ner Owner's Name /
information is fills
required for every 4
page. City/Town State Zip Code Date of Ins ection
D. System Information (cost.)
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.):
Fyn.313 Title50ffidd Inspec bon Form Subsuiace Sewage Disposal System-Page 14 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage
Disposal System Form -Not for Voluntary Assessments
Property Address
Cw ner Cw ner's NarnAlarflois
/� /
information is required for everyAN U�b� / l
page. C yfrown State Zip Code Date of Inspec on
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two per ent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where p ' water supply enters the building. Check one of the boxes below.
hand-sketch in the area below
❑ drawing attached separately
Q3- IV , '
trns,3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments
` fir
Property Address �—
1
ON norrm Ow ner's Name �V�b�r� l/information is �✓S �f �/S
12M4
required for every
page. City/Town State Zip Code Date of Insp coon
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet oC
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ erved site(abutting property/observation hole within 150 feet of SAS)
Checked with local oard of Health-explain: /
P/,A kt s -f- 7_FS f
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
16?PV1 A"o- p-
p ✓t � �
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ris•3r13 Title 5 Official IropecbmForm Subsuiace Sewage Disposal System-Page 16d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
/,S 4
Os ner Om ner's Name �/f '
information is . ,Zl / /�<s Od IV l�
required for every
page. Cityrown State Zip Code Date of hfmcti
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
nspection Summary D(System Failure Criteria Applicable to All Systems)completed
Sys nformation—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
tyny.,y13 Tift50fficial Iris pec bon Form Subsurface Sewage Disposal System-Page 17 d 17
TOWN OF BARNSTABLE v
LOCATION SEWAGE #
VILLLAGE?2 Z ASSESSO S MAPS& LOTO 7Z ,/0
3NgPe_r-VkS,NAME&PHONE NOUe2 i
SEPTIC TANK CAPACITY J600 UP A2;6e: .rDZLj.
LEACHING FACILITY: (type) (size) 1666
NO.OF BEDROOMS—
BUILDER OR WNE
PERMITDATE: COMPLIANCE ATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
. within 300 feet of leaching facility) Feet
Furnished by
r
'M l
W l
(�1
• O
u11
� a O�
+iO CAT IO a. SEWAGE PERMIT NQ.
`YLLLAGE
I N S T A Li R'S NAME & ESS
B UILDER OR OWNER
I
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
t--`'
.?
�. .
- o :
i i �� . .
U
� �
.:,,:
—�
No e yi . i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
..................... ....................OF.............................I....................................................
Appliration for D.hipv ial Works Tonstrurtiaatt Urrutit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot # 10 — Sandy Valley Rd 4rstons Mills !# j�°,A....... -
... .--•--•---.....•--......... ...... ............................. ..--•---..• ------.----
Capricorn ReikYtyEst 765 Falmouth Roff&, Hyannis
----•-•-••-•-•-•------............................•--..............-••---..............--...---.. _............----..........._----....--•-..................---•--.....----.....----••......-------
w Steve L e b e l Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedroo arch •••.Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Buildingr........................... No. of persons............................ Showers Cafeteria ( )
Other fixtures ............................
w Design Flow..__..55 : 000---.gallons per per on,p�er day. To a; 1oY flow 33� �.gal�lons.
WSeptic Tank—Liquld cap --------- Len Len WidA................ Diameter------- Dept._._._._.._..__.
xDisposal Trenc —No. .................... Wi l�.................... Total Length....-.r........... Total leaching area.._ sq. ft.
Seepage Pit N ..................... Diameter................ Depth below inlet................... Total leaching area 266......_..sq. ft.
z Other Distribution box ( ) Dosi t nk (-
AareW Engineering 11-25-81
Percolation Test Results Performed by........................................ . i Date......................_.................
a 2.Q 2 one encounte
a Test Pit No. 1. minutes per inch Depth of Test Pit.. Depth to ground war -------------- —
(i, Test Pit No. A_ ._._._..minutes per inch Depth of Test P ..A.............. Depth to ground waterNl'�............_... e
---------------------------------C••••----•-•-••..................................................................................
O Description of Soil.......�_r:..-...? 1 oam & tO s O11
y • ----•-
x _ 2 - 1•n •-•�••Ti�iedium�-_--e Yow sand
10 - i'2 meal: white sand traces oi'. ._-raveT` no water at 12 '
------------------
- w ------------------•-••---•--•--..........----------- -•••-•--....... �••--•-....,.•._;..•••-•-•••--••-•--•......•-----.....
' J
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
...----••••---•---•••••-•-•--•-•...................••-•-••-._...-•••------•------••--••••---••••••--•••••-•--••-•---•---•----•---••--........----------••-•--- .........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance n issued by the boa, of health.
Signed...1 ..................... ..... ............
Date
Application Approved By......... . . --••• ----•• ..... ._...y....._....
Date
Application Disapproved for the following reasons:.....................................•------•---------------.....-----------•---•••---•-•-=......-••...........
........................•--•-------...................-•-•--•---.............-•---•--•-••-•-----•--. ..................----------•-.......•.................... ••------.... ..._.........
Date
PermitNo....................................................... Issued................-•-•---•---•--•----••---•--•------•-...
Date
-- --- --
NO. r ti i FEs........... .. Owl
COMMONWEALTH OF M;A$SACHUSETTS
BOARD OF HEALTH
Town FB arnstabl e
O .......................................................................................
.� Apli iratiott for Uiiipoiial 10orkii Tnnitrur#inn Pamit
Application is hereby made for a Permit to ConstructN ) or Repair ( ) an Individual Sewage Disposal I,
System at:
T,ot # 1-Q - Sander Valley h.c'Kl& tons Mills i, RA
... .... .............................. --------•-----................--•-•----••-
Capricorn Rehl y- rust. 765 Falmouth Roffe, Wyannis
------...........................•-..............--•---------.........-•---........... ......---••-----•---------....................----..............--•---......._.........--••--_....
W Steve L @ b el Owner Address
-------------•----•----.....-•--••------•••----•----._...................--•---•----............_
Installer Address
Q Type of Building Size Lot............................Sq. feet
V g— _..,Expansion Attic ( ) Garbage Grinder ( )
Dwelling No. of Bedrooms........................ .............
'4 Other—Type of Buildiii aneh No. of. persons............................ Showers
a YP i�-•-••-•--•-•................ p Cafeteria ( )
Otherfixtures .............•-•----........-•---------•--•--•--•-•-•----•.._..--.•-•...--••-........._....-••••-••••-•-----------•-•••-...........---....---.------
W Design Flow......55..................................gallons per person per day. Total daily flow......
..330_.___........_. De ...'. „Ions-
WSeptic Tank—Liyuid capacit�+_._____:....gallons Leng .__.............. p s ft.
x Disposal Trench—No, 'a 000 Wi th................ Total Length...__..10 Total leaching area..__ q.
Seepage Pit N�.............,...._... Diameter.................._. Depth below inlet.................. Total leaching area266 sq. ft.
Z Other Distribution box ( ) Dosin tank (( ) ,
rldreclge Engineering 11-25-81
Percolation Test Results Performed by....................... Date......_..........._.....................
aTest Pit No.,L12 . . . minutes per inch Depth of Test Pit1/2.............. Depth to ground wat@PnJJe encounter- ,
ri, Test Pit No.IYI.A...........minutes per inch Depth of Test P��1A.............. Depth to ground wateiW...................
e
0 -----------------------------------•----....--•-•-------.........------....-•--•----•-•-•---•--••--..............---------••-•------••--------•-•...---..•---
O Description of Soil....... 2.'...__....loam & topsoil 1,
x 2' - 10' i -----.....•--• •------------------------------------•-•---------------•-------------------------------
.� edium yellow sand
••--
10' - 12' med. white sand traces of ravel•- no water at 12 '
x ----------------------------- •---..-- g �.--...----
U Nature of Repairs or Alterations—Answer when applicable..........................................................................................
---- ----------------------••--•---------------•--•-----•-•--••-••••-......-•--•--•----------.
Agreement: i.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance Vith
the provisions of TITLE 5 of the State Sapitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance "asbe �issuedby board o lth.
res.Signed. /�..:... .. ��. -...z/
----------••......•... •-------
Date
Application Approved By.......... ..... . .
---•-----------•--- P
Application Disapproved for the following reasons:---- ••-•--.....-•------•--••----•.......-----•--•-•-••-••-•••-••••--••......-- --.."-t..............
---------------------------•-•---•------••-----------------•--•--••----....•-•••-------•--......................------•---•------...-------•---••---••......•---•---•-•- ••--••......----•---.....
Date
PermitNo.......................................................... IssuecL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
POARD OF HEALTH
........Town....................OF....Barnstable ........................
.......................................
Trrtifitatle of Toutplittnrle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
Steve Lebel
at......Lot... ....10 - Sandy Valley Road,Ins`atarstons Mills , P.'A
----- - - ---------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....... . I!..... 3.?...... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOW`; TR E® AS A GUARANTEE THAT THE
SYSTEM• WILL FUNCTION SATISFACTORY. ",PONS
f
DATE......................... f ....................................... Inspector--•-•-• -
THE COMMONWEALTH 0F'MASSACHUSETTS
,BOARD OF HEALTH,
Town ... .OF.Barnbtable.......................................
No4ftJ_ (t 3.... FEE....,,-•d
Disposal Efforkv 6notnution firrutit
reby granted.. Steve -Lebel
Permission is -------------------ye.,--.....:..-...---------••-•-•---...•-•---••----------•-•-•••••-••-••-•--•.......•---••....................-----
to Construct Re ai ) a Individual Sewage Disposal System
r� ) -P S�a�d 'alley hc7. �ivl P y r
at No... o t .ar s to ns M 11 .--,> ' ----------------------- .......................
w Street
as shown on the a plcatio for Disposal Works Construction Permit No..................... Dated..........................................
sJ Z adth
DATE........•--`---... Y
FORM 12$$ A M. SULKIN, INC., BOSTON I
i �
( 'OT"p cl O
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pNo.10951 O
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P''� ✓�ram_, C�![� 1ot /�rai TTC,Sc�i,ZTs� G E
LEGEND L
EXISTING SPOT ELEVATION ,: OxO
CERTIFIED PLOT PLAN
' "EXISTING CONTOUR ----- 0 —:---
FINISHED SPOT ELEVATION`.'',:' Pcy RIFE; �� Lnr lD S'A,vgy I�iguEy T{'�, Mnaso�s MILLS
FINISHED CONTOUR. 0
--�--- erce -�
E�or��o , i N
APPROVED, BOARD OF HEALTH ` '
DATE,. . AGENT _ SCALEs I • -,30' DATES MAy
LDREDGE ENGINEERING CQ 1:
C ;IENT,�,�;�1,:�.,. ,.:. 1 CERTIFY THAT THE PROPOSED
EGISTERE REBI'TE;R.ED ` ,IOs,�yp.-' BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
OF BARNSTABLE* WAGS s�:�a�)
712' MAIN` STREE'f,.
t:`. H YA N N 13, M:A�S ' s gNEET.�t... OA. E REG. LAND SURVEYOR
/VOTE /F E/TNLeR TIlE SEPTIC TANK OR
20 FT. M/N. LE,4CA,I//VG .Z'/T ARE MORE THA.V 12"BEJ.0-OV
/O p7 MIN. r:;RA DES A P4',0/AMETEK CoNC^FTE C'ONER'
SHALL B! AR006N7- TG GRAOE. EXnk-A
CONCRETE 4+PYC O/PC rEAVY CAST /RON C0V/—R S1/.44L &,= USL-O
L=L. 6 2 0 COYERS W/N. P/TCN /F/IV OR/VEyVA Y
e P1�ip FT
2 . /N. CDiVC'RE•TE
A G1�AOME CO ►DER C'L EA/V .SANG
o—
- - UQu/o LEYEL -
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4"CAST Z LAYER
/RON P/PE c / U o p
'drr G•,L
M/N.P/TCN ' e • • • • • ° • • • v �4 �ygSHFO S7L�NE
%4 P�K R7 SEPTIC TANK D/ST, o • s • • • • • • • • • e .
oz
• • • • • DEPTH • • • f • v . A.SlHED STONE
. ;sac.. - � o • r • • • ••• i �
411
7� x / o — ► a� • • • . • • • • . D pop PRECA5T SE.E.FA4GE
t Nt/,eRT G'L E{/AT/OAI S P/T ��-x+<��'4 y e �e • r f • • • • • • • s .v P/7 DR EQU/V.
IMMERT AT al!/LD/NG FT. 6 fT D/AM.
/NL ET SEPTIC TA/VK .5"7. 5 ,O ' /p FT. D/AM. y C CSEE 7.owL/LATJON,
0U71-ET SEPTIC TANK S7•3 FT.
J/VLET DISTR/aimo V BOX S 6 .8 Ic"7 GROUND WATER TADLE
0tI7LETD/3TR1.9&-r/ON BOX 5' •6 FT. SECT/O/V CF .
//VL67' L.EACI'!/IVG F-jT S"�.�FT S'�'wAGE O/.SPASA L SYSTEM -rAOMAT/GN
LEACH//VG P/T
.SCALE �� OJMENS/ON A4 ITT.
DRS/GN CRITERIA ol�rENs/ON 8 6 F'T•
NUMBER OF BEDROOMS 3
DIMENSION C 4 FT /y1 i N.
GARB,4GE 0/SPO.SAL UNIT /✓O n/H SOIL_ LOG
TOTAL E,3T//N.4TEp FLA/oN 3 3 b G.4L.1DAV SOIL. TEST #/ SO/L TEST*2 SD/L TE$T
A(UMBER 0.1w LEACN/NG 0/T,5 I fE[E✓. 5 3 ,r-EL&rY. GATE OF SOIL TEST
S/OE 4,EACH7NG PER P!T 8-9 SQ PT. p — Z_ ' RESULTS Jt/ITNESSED dY
BOTTOM LEa°ICN/NG PER P/T $Q. RT. L J-q /lq PER COLAWO" RATAr M.1AIVINCH
TOTAL LEACHING AREA �t. 6 SQ. FT. 57 U/,3 5 a IL. AEN COLA T/oN RATE
RESERI/E LEACNlN6 AREA Z-�' b SQ. FT
YCST P-Z7 S
F Al
q� Iv
/'•''r/L L.S
v /1MORSE
No.10951 O
� EL DREDGE ENG/NEAR/NG CV,INC.
�,� ;s pp��GfSTE���� EL 4 5"-.3 7JZ MAIN ST., HYANN19, MASS-
E FS"IONAL�N NO GROUND LNiaTE/P E/VCOUNTEREO CLIENT: - x,^,yCv 9,ITE=S /7 0¢
� GRO ClNO yVL1 TER AT E'L.Ei/ 7-S SHEET z OF z
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessaiy signatures on this format 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St.-, Hyannis, MA 02601 (Town Hall) and get the Business Ceitificate that is
required by law.
r 'TI 'F4�t �u`,'3 DATE. l 3 1 2c+t1 Fill i please:
,yt a,rT�'" °a APPLICANT'S YOUR NAME/S: 12 aCt A•lt�av�� ��+or.. �h�l�0 Ayc�l��f
BUSINESS YOUR HOME ADDRESS: 1SS' !9 yo\l �4� M.rs3+v i M�IIs
_TELEPHONE Home Telephone NumbertS--
r aµ� �10 �;��j%
}F ai4 crdP. rP ��. EIN',or, '2- Z2 I$ Email Address n trwA Cp rJ�aa� r Ca tra Had CC,",..
NAME:OF'CORPORATION`'
NAMEOF NEW'BUSINESS' : 4r:t a TYPE.OF BUSINESS Prra fj'!A tk&AG C,LAhAt.�
IS THIS A HOME OCCUPATION?. YES NO. / ,
ADDRESS OF BUSINESS .N . 1 s •�S MAP/PARCEL NUMBER I f ` LQ (Assessing)
02(e6t C
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'intehded 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 legall operate our business in this town.
1. BUILDING COMMISSIONE OFFICE �� � ��R�ULES AOND MPLY R GUILATIONS.EFOAILURE TO N
! This individual has bee 'nfo ed of any p r it requirements that pertain to this type of busii@@MPLY-MAY RESULT IN FINES.
ut zed _ i atur
COMMENTS:
2. BOARD U HEALTH �p
This individual has been inform 'd,.q4(' rmit requirements 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:
V
;✓ ' � V v���i�)/Q// C ✓
/� 1 0 7,Q /D , S a 9
BORTOLOTTI CONSTRUCTION, INC. S�p' 1 `
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 ►A %o V 19
h`rs 9?
508-771-9399 508-428-892(► FAX: 508-428-9399 ?4gRysrgg�.
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
PART A `
CERTIFICATION
Property Address: ahl-kz1a
Date of Inspection: Ins cto 's Name:
Own '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 stems. The System:
V Passes
Conditionally Passes
Needs Further Ev tion the Local Aproving Authority
Fails
Inspector's Signature: Date: �7
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 SLIM ARY:
A)SYSTI PASSES:
�✓/ 1 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
exfiltration,or tank failure is imminent. 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 -
.y
'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).
on if with approval of The Board of Health):
The system will pass inspection ( pp
Broken pipe(s)are replaced
Obstruction is removed _ a
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
eq
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALT
H PUBLIC WATER AND U
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 100 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.
tank and soil absorption system and is less than 100 Feet but 50
The -stem has a septic rp Y
�'
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 nitrate 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 6"below invert or available volume is less than 1/2
day flow. ,
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
II
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
CHECKLIST
Check if the following have been done:
yPumping 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.
_L.-'As-built plans have been obtained and examined. Note if they are not available with N/A.
_IGThe facility or dwelling was inspected for signs of sewage back-up.
_k,4he system does not receive non-sanitary or industrial waste flow.
__4,--Ihe site was inspected for signs of breakout.
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-
ted for condition of baffles or tees, material of construction,dimensions,depth of liquid,
, s h of sludge,depth of scum.
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.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
!/ provided with information on
The facility owner and occupants, if different from owner were ov ded
tY ( P ) P
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow:330 gallons Number of Bedrooms: Number of Current Residents:
Garbage Grinder:_ Laundry Connected To System:( Seasonal Use: xk
Water Meter Readings, if ailable: Q
Last Date of Occupancy: -
�OMMERCLALANDUSTRLAL: A)c) -
Type.of Establishment:
Design Flow: gallonstday Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
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 information: '�-
System Pumped as part of inspection:_ If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
APPRO T7 AGE of all components,date installed(if known)and source of information:
Sewage odors detedied when arriving atdhe site:
-4-
.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: " Material of Construction: 4"'co-ncrete metal FRP Other
(explain)
Dimisions: S ' Sludge Depth: Scum Thickness: l"
Distance from top of sludge to bottom of outlet tee or baffle: cgz
Distance from bottom of scum to bottom of outlet fee or baffle: "
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
I 1 mAeyla�t�iion to outlet invert,structural inte rity,evidence of leaks ,etc.) a O
t%f.C.fLF qi�Ka'1
jy
GREASE TRAP: A)Q
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:-gal Ions Design Flow: gallonstday
Alarm Level:
Coniments:-(conditiori of inlet tee,condition of alarm and Boat switches,etc.).
DISTRIBUTION BOX: V/
Depth of liquid level above outlet invert:
Comments: (note if JRvel and distribution is eq al evi nce of solids car over,evidence oC eakage into
or ut of box,etc.) yt. ,lt Ct� Q,,L m_��
,. G1,� ��r ram%
PUMP.CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
II
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,signs of raulic failur level of ponding,condition of vegetati n,
etc. 0(XJ - n
CESSPOOLS: (�
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(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:—A(J
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 ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
toll
d-
t
�a
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Method of Determin donor Approximation:
rota Q'
-7-
t
Safe Earth Systems j
P.O. Box 1359
b Marstons Mills, MA 02648
508-576-8645
Address of Property: 185 Sandy Valley Rd.
Marstons Mills, MA 02648
Owner's Name: Gail Kahn
Date of Inspection: 7/21/95
PART A CHECKLIST
_x_ Pumping information was requested of the owner, occupant
and Board of Health.
_x_ None of the system components have been pumped for at
least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have
not been introduced into the system recently or as part of
this inspection
_x_ As built plans have been obtained and examined.
Note if they are not available with N/A.
_x_ The facility or dwelling was inspected for signs of sewage
back-up.
_x_ The site was inspected for signs of breakout.
_x_ All system components, excluding the SAS, have been
located on the site.
_x_ The septic tank manholes were uncovered, opened, and the
interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth
of liquid, depth of sludge, depth of scum.
_x_ The size and location of the SAS on the site has been,
determined based on existing information or approximated
by non-intrusive methods. 'NE
REEEO �s
_x_ The facility owner (and occupants, if different from ow
were provided with information on the proper maintenan�c�e 2 8 199�
of SSDS. wool
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81 �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
,FLOW CONDITIONS
If Residential
_2_ Number of bedrooms
_3_ Number of current residents
_NO_ Garbage Grinder (yes/no)
YES Laundry connected to system (yes/no)
_NO_ Seasonal use (yes/no)
If Non-residential
_n/a Calculated flow
Water meter readings, if available: N/A
_N/A Last date of occupancy
General Information
Pumping records and source of information:
_NO System pumped as part of inspection (yes/no)
If yes, volume pumped
Reason for pumping:
Type of system:
_X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes/no) (if yes, attach previous inspection
records if any.)
Other; Explain
Approximate age of all components. Date installed, if
known. Source of information:
System 10 years old. Date Installed unknown
Source: Septic Permit #84-433 Barnstable BOH
NO Sewage odors detected when arriving at the site (yes/no).
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SYSTEM INFORMATION continued
Septic Tank: _X
(Locate on site plan)
Depth below grade: _24inches_
Material of construction : x concrete metal FRP_ other
(explain)
Dimensions: Holdinq Tank apprx. 7' x 8 , D/Box 24"xl2"
3" Sludge depth
3.5' Distance from top of sludge to bottom of outlet tee or baffle
V Scum thickness
4" Distance from top of scum to top of outlet tee or baffle
10" Distance from bottom of scum to bottom 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,
recommendations for repairs, etc.)
Recommend Pump System. Condition of inlet & outlet tees is_good Structural integrity
okay. Depth of ligulid level is even with bottom of outlet invert. No evidence of leakage
Distribution box: _X_
(locate on site plan)
0 Depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage
into or out of box, recommendation for repairs, etc.)
Liquid level is even. No evidence of solid carry over or leakage.
Pump Chamber: _n/a_
(locate on site plan)
_n/a_ Pumps in working order (yes/no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc.)
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SYSTEM INFORMATION CONTINUED:
Soil Absorption System (SAS): X_
(locate on site plan, if possible; excavation not required, but may be approximated by
non-intrusive methods)
If not determined to be present, explain:
Type: Leaching Pit
Leaching pits and number 1
Leaching chambers and number
Leaching galleries and number
Leaching trenches, number, length
Leaching fields, number, dimensions
Overflow cesspool, number
Comments: None
(note condition of soil, signs of hydraulic failure, level of ponding, condition of
vegetation, recommendations for maintenance or repairs, etc.)
CESSPOOLS (locate on site plan):
Number and configuration n/a
Depth-top of liquid to inlet invert
Depth of solid 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 soil, signs or hydraulic failure, level ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
PRIVY: N/A
(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, recommendations for maintenance or repairs, etc.
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_) J85. -Sandy Valley Rd. Lot #10 (Kahn)
SYSTEM INFORMATION continued
Sketch of Sewage Disposal System:
Include time to at least two permanent references, landmarks or
benchmarks.
Locate all wells within 100'
AUG 4 1995 �d '
HEALTH M"..
vl
1996 N
PARCQN�
Note-
Depth to-groundwater UnKnownvr'
Method of determination or approximation:
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PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If"not determined", explain why not.
_N_ Backup of sewage into facility?
_N_ Discharge or ponding of effluent to the surface of the ground
or surface waters'?
_N_ Static liquid level in the distribution box above outlet invert?
_N_ Liquid depth in cesspool <6" below invert or available
volume < 1/2 day flow?
_N Required pumping 4 times or more in the last year?
Number of times pumped
_N Septic tank is metal? cracked? structurally unsound?
substantial infiltration? substantial exfiltration? tankfailure
imminent?
_N_ Is any portion of the SAS, cesspool or privy: below the high
groundwater elevation?
_N Within 50 feet or a surface water?
_N_ Within 100 feet of a surface water supply or tributary to a
surface water supply?
_N_ Within a Zone I of a public well?
_N_ Within 50 feet of a bordering vegetated wetland or salt
marsh (cesspools and privies only, not the SAS)?
_N_ Within 50 feet of a private water supply well?
_N_ 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.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INFORMATION FORM
PART D
CERTIFICATION
Name of Inspector: Michael DiMaggio
Company Name: Safe Earth Systems
Company Address: 135 Rte. 130, Mashpee, MA 02649
Mailing Address: P.O. Box 1359, Marstons Mills, MA 02648
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems.
Check one:
_X I have not found any information which indicates that the
system fails to adequately protect public health or the environment as
defined in 310 CMR 15.303. Any failure criteria not evaluated are as
stated in the Failure Criteria section of this form.
have determined that the system fails to protect public health
and the environment as defined in 310 CMR 15.303. The basis for this
determination is provided in the Failure Criteria section of this form.
Inspector's Signature 's
Date 7._. a
Original to systems owner
Copies to: Board of Health
Buyer (if applicable)
Approving Authority
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