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HomeMy WebLinkAbout0110 SANTUIT-NEWTOWN ROAD - Health 110 Santuit-Newtown Road,Marstons Mill A= 031 005 - 006 ®� --- O i l ; ♦ 4 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal ySystem Form -Not for Voluntary Assessments 110 Santu it/Newtown Road Property Address i s Nancy Soule ' Owner Owner's Name s information is Marstons Mills MA 02648 2/10/2014 required for every page. City/Town ' State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms fl on the computer, U use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. a: r t , Company Name P.O. Box 49 Company Address m Osterville MA 02655 Cityrrown State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally ittspected 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: r ® Passes i ❑ Conditionally Passes ❑ Fails ❑ Needs Further luatioh by the Local Approving Authority 2/17/14 Ins c is lgnature Date Th sy tem inspec or shall submit a copy of this inspection report to the Approving Authority(Board of He Ith 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. L ****This report only descri bog conditions at the time of inspection and under the conditions of use at that time. This inspedidn does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 t Title 5 Official Inspection Fo surface Sewage Disposal System•Page 1 of 17 f I , Commonwealth of Massachusetts W Title 5 Official) Inspection Form Subsurface Sewage Disposal`S.yytem Form- Not for Voluntary Assessments 110 Santuit/Newtown Road Property Address Nancy Soule Owner Owner's Name information is required for every Marstons Mills MA 02648 2/10/2014 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: I 1 i . 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. s Check the box for"yes", "n ";or"not determined" (Y, N, ND)for the following statements. If"not determined," please explai . The septic tank is metal and'goVer 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substan(!Ul!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. t *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that:th,e tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 3 1 I d n l5ins•3113i: Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Officia ;inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Santuit/Newtown Road Property Address ; Nancy Soule I Owner Owner's Name information is required for every Marstons Mills MA 02648 2/10/2014 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.)�` ❑ Pump Chamber pumps/albirms 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(withapproval 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),arereplaced El El El ND (Explain below): 4 , 1 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ry, r 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 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 y Commonwealth of Massaciusetts Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V-0 M 110 Santuit/Newtown Road y.. Property Address Nancy Soule Owner Owner's Name 4L4 information is required for every Marstons Mills MA 02648 2/10/2014 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: r 9 D) System Failure Criteria Ap�licable to All Systems: You must indicate"Yes' lot"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 El ® DiscUrge or ponding of effluent to the surface of the ground or surface waters due to'ari overloaded or clogged SAS or cesspool ❑ ® Static Iligyid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid:depth in cesspool is less than 6" below invert or available volume is less than_%/ day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 � Massa: .. Commonwealth of Massachusetts Title 5 Official! .Inspection Form Subsurface Sewage Disposal.,Sy'stem Form- Not for Voluntary Assessments 110 Santuit/Newtown Road Property Address Nancy Soule Owner Owner's Name information is MA 02648 2/10/2014 required for every Marstons Mills i; . page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 1 f: Yes No Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® q P P 9 Y 99 obstryp ed pipe(s). Number of times pumped: ❑ ® Any pbrtion of the SAS, cesspool or privy is below high ground water elevation. {, t ❑ ® Any pbrtion of cesspool or privy is within 100 feet of a surface water supply or tributary, , o a.surface water supply. .. ❑ ® Any portibn of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portibn of a cesspool or privy is within 50 feet of a private water supply well. i , ❑ ® Any 06rtion of a cesspool or privy is less than 100 feet but greater than 50 feet from ta-private water supply well with no acceptable water quality analysis. [This system,passes if the well water analysis, performed at a DEP certified laboraltory,for fecal coliform bacteria indicates absent and the presence of amipionia 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- 10,00060d. ❑ ® The 4s1 tem 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 systerr,owrier should contact the Board of Health to determine what will be nece", ary to correct the failure. 4 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 midst;indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the S`�iate`m is within 400 feet of a surface drinking water supply ❑ ❑ the sygte.m is within 200 feet of a tributary to a surface drinking water supply E] Elthe§ystem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—MPA)or a mapped Zone II of a public water supply well If you have answered "yes,"tb any question in Section E the system is considered a significant threat, or answered "yes" in Sectibrx D above the large system has failed. The owner or operator of any large system, considered a signit'ic6t threat under Section E or failed under Section D shall upgrade the system in accordance with:3.10 CMR 15.304.The system owner should contact the appropriate regional office of the Deportmgnt. t5ins•3/13 o Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 f � Commonwealth of Massachusetts Title 5 Officia Inspection Form Subsurface Sewage Disposal,System Form Not for Voluntary Assessments "M 0 110 Santuit/Newtown Road Property Address e Nancy Soule Owner Owner's Name information is MA 02648 2/10/2014 required for every Marstons Mills r � �: page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have&n 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 y;of the system components pumped out in the previous two weeks? , k ® ❑ Has thO 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 dl 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 si{s�ee'and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existirj'g;',Mormation. For example, a plan at the Board of Health. ® ElDeterr9irjed 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)] C D. System Informatig' is Residential Flow Conditi6lI s: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 31 b i„MR 15.203(for example: 110 gpd x#of bedrooms). 220 y, i+s li Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t5ins-3/13 ( P 9 P Y 9 { i; r Commonwealth of Massachusetts Title 5 Official-: Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments �M ,•'' 110 Santuit/Newtown Road Property Address Nancy Soule ^ ' Owner Owner's Name information is 1 required for every Marstons Mills !` MA 02648 2/10/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: kN 1, pp i Number of current residents; 2 Does residence have a gar l a e grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected?;` ❑ Yes ® No Seasonal use? ;` ; ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: is unavailable Sump pump? ❑ Yes ® No currently Last date of occupancy: f(" Date r ` Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/ ersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tanks 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 tz Commonwealth of Massa' W Title 5 Official] Inspection Form Subsurface Sewage Disposal!System Form -Not for Voluntary Assessments °M 110 Santuit/Newtown Road Property Address ;. Nancy Soule )' Owner Owner's Name information is required for every Marstons Mills MA 02648 2/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/used Date Other(describe below): ' General Information it! Pumping Records: r i Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped`determined? 4 . Reason for pumping: maintenance Type of System: 'I; ® 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 y : ❑ 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 u - it . i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal%y''stem Form -Not for Voluntary Assessments 110 Santuit/Newtown Road Property Address Nancy Soule Owner Owner's Name information is required for every Marstons Mills _ MA 02648 2/10/2014 page. Cityrrown (; State Zip Code Date of Inspection D. System•Information •(cont.) Approximate age of all components, date installed.(if known)and source of information: installed -unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on pite plan): Depth below grade: fq: 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.): 5 t 1 Septic Tank(locate on sitelplan): 12" Depth below grade: 4`y 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: y 1000 gals. Sludge depth: 2" �1 15ins•3/13 ! Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I I. it Commonwealth of Massachusetts y v Title 5 Official-Inspection Form Subsurface Sewage Disposal5ystem Form -Not for Voluntary Assessments M 110 Santuit/Newtown Road ?� Property Address ¢ Nancy Soule Owner Owner's Name information is required for every Marstons Mills MA 02648 2/10/2014 page. CityfTown State Zip Code Date of Inspection D. System Information'(cont.) Septic Tank(cont.) Distance from top of sludgeifd.hottom of outlet tee or baffle 29 Scum thickness 6 6 Distance from top of scum to.top of outlet tee or baffle Distance from bottom of scut rri to bottom of outlet tee or baffle 15 How were dimensions determined? measure ;y Comments (on pumping recdmmendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to out invert, evidence of leakage, etc.): The tees were present. There was no sign of leakage.The tank was pumped after the inspection. y t Grease Trap(locate on site plan): l; Depth below grade: feet Material of construction: ❑ concrete ❑ mull ❑fiberglass ❑ polyethylene ❑ other(explain): N/a .i Dimensions: y Scum thickness i! 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 R t5ins-3113 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t, y Commonwealth of Massachusetts W Title 5 Official.., Inspection Form s Subsurface Sewage Disposal irSystern Form - Not for Voluntary Assessments 110 Santuit/Newtown Road Property Address i' Nancy Soule Owner Owner's Name I information is t;, required for every Marstons Mills MA 02648 2/10/2014 page. Cityrrown State Zip Code Date of Inspection D. System Informatio (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to oufilet invert, evidence of leakage, etc.): l . f; Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: . ❑ concrete ❑ met' I'. [Ifiberglass ❑ polyethylene Elother(explain): yl�. N/a 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 i. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Santuit/Newtown Road Property Address Nancy Soule Owner Owner's Name information is required for every Marstons Mills MA 02648 2/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present<;mbst be opened)(locate on site plan): Depth of liquid level above outlet invert n/a 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.): q ' :n Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: El Yes El No* . 1, r Comments (note conditionf dump chamber, condition of pumps and appurtenances, etc.): is * If pumps or alarms are not-Jn,working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain My: r t, t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 V Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments , ,M 110 Santuit/Newtown Road Property Address Nancy Soule Owner Owner's Name information is required for every Marstons Mills MA 02648 2/10/2014 page. City/Town State Zip Code Date of Inspection D. System Informatioh -(cont.) Type ; ® leaching pits number: 1 -6x6 1000 gal. ❑ leaching chambers number: ❑ leaching gallerigs number: ❑ leaching trenches number, length: ❑ .leaching fields, number, dimensions: ❑ . overflow cesspool number: ❑ innovative/alternative system I ' Type/name If technology: Comments(note condition b.f soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 3'of water on t'he'bottom.There was no signs of failure. The cover was 15" i r y, Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration N/a Depth—top of liquid to inle` invert Depth of solids layer Depth of scum layer Dimensions of cesspool ri Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t; t: t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Santuit/Newtown Road "d Property Address Nancy Soule Owner Owner's Name information is Marstons Mills MA 02648 2/10/2014 required for every _ page. City/Town 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.): N 11 I i i` Lj Privy(locate on site plan): Materials of construction: Dimensions Depth of solids I Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a .I i 5. k i i 5 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 A, I ' e Commonwealth of Massachusetts , Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k+ °M 110 Santuit/Newtown Road Property Address Nancy Soule Owner Owner's Name , information is required for every Marstons Mills f MA 02648 2/10/2014 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 arealbelow ❑ drawing attached separjtely 0, QQ A I II � a3aaq 3 � 3 S'q g r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 ri •. r Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal Form-Not for Voluntary Assessments 110 Santuit/Newtown Road Property Address Nancy Soule {I Owner Owner's Name information is required for every Marstons Mills MA 02648 2/10/2014 page. City/Town State Zip Code Date of Inspection D. System Information f(cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells , 70' +/- Estimated depth to high ground water: feet Please indicate all methods;"used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date 1! l ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Using topo and water contours maps ❑ Checked with 16cal excavators, installers-(attach documentation) ❑ Accessed USG database-explain: t is You must describe how you.6stablished the high ground water elevation: . :1 see above. i i li 1. I` 1 ' t Before filing this Inspectipp Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 t. '. ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposalySystem Form - Not for Voluntary Assessments 110 Santuit/Newtown Road " Property Address {: , Nancy Soule Owner Owner's Name C information is required for every Marstons Mills ,{ MA 02648 2/10/2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A I Ef,l C, D, or E checked ® Inspection Summary D 1(S�Stem Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ' i '1 1 I a� 11 '1 1 1 , A, I ! q� 7 l I. i s; a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 R q TOWN OF BARNS,tT�ABLE LOCATION '',�pp�, Q SAMIUi1 4e-� 1�(X 2-s SEWAGE# VILLAGE_V4AtS � , ASSESSOR'S MAP&PARCEL ,I`3-S-TME&PHONE NO. +i'®L� \�v���s� .��'-���-S�p C SEPTIC TANK CAPACITY LEACHING FACILITY:(type)��r� (size) NO.OF BEDROOMS �L OWNER `f�rJ,ti';/azp d�c1/ZT�4 ME I�P'DATE: �Z A� COMPLIANCE DATE: A�r7 epara on Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility r Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r r ; w , 110 Santult Newtown RD n Marstons Mitts, MA 02648 .t Rear of House B A Deck 1 1 1000 Gallon H-10 2 Septic Tank � J I' A 1-27' B 1-24' 2-32, 2-29' 3-59' 3-55' i I ' 0 6' (R=6') Leachpit, 1 , 3 W I v i r - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments 4M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6115/2000. Inspection forms may not be altered in any way. A. Certification Important:When filling out forms 1. Property Information: s on the computer, sv - use only the tab 110 Santuit Newtown Rd C) key to move your Property Address — cursor-do not use the return Martha & Donald Baker � key. Owners Name y 110 Santuit Newtown,Rdco Owner's Address "ITV Marstons Mills MA 10?648 I City/Town State Zi Code Date of Inspection: 05/29/07 c- Date 2. Inspector: Mike Hudson Name of Inspector Septic-Wiz Environmental Services Company Name 32 Midway Dr Company Address Centerville MA 02632 Cityrrown State Zip Code 508-367-5669 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 ❑ s Further aluation by the Local Approving Authority 06/11/07 Ins ors Sign 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. 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments GM Subsurface Sewage Disposal System Form A. Certification (cunt.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 City/Town State Zip Code Baker 05/29/07 Owner's Name Date of Inspection 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: The System passes by DEP standards at time of inspection however under an increased load the SAS has a limited life expectancy of not more than a few years. All effluent limits pass by DEP standards but recommend pumping system due to near required pumping levels. NY& — B) System Conditionally Passes: 77 ❑ 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 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: / I 110 Santuit Newtown Rd-T5 Inspection.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 City/Town State Zip Code Baker 05/29/07 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution 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: N /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 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 "0 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection tJ/A, _ C) Further Evaluation is Required by the Board of Health (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 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: 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cityrrown State ZipCode Baker 05/29/07 Owner's Name Date of Inspection 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 A _ ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of 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 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. 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments M Sve- Subsurface Sewage Disposal System Form A. Certification (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 City/Town State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Tjl41 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. 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments lug Subsurface Sewage Disposal System Form B. Checklist 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection 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(3)(b)] 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 110 Santuit Newtown rd Property Address Marstons Mills MA 02648 Citylrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2005-271 GPD 2006-210 GPD Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title_ 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Citylrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Water Pollution Control-last pumping on file 11/24/01 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: n/a gallons How was quantity pumped determined? n/a Reason for pumping: n/a Type of System: ® Septic tank, 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: 23 years, installed in 1984 via of construction permit on file at BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 City/Town State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 26"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 8'6"Lx4'10'Wx5'8"H- 1000 gallon Sludge depth: 4'8"(2'thickness) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" 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 16" How were dimensions determined? Measured stick w/hinge, tape,floodlight, mirror 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 110 Santuit Newton Rd Property Address Marstons Mills MA 02648 City/Town State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping every 36 months, inlet and outlet tee and baffle in good condition, tank appears structurally sound w/no evidence of leakage,effluent levels normal in relation to inlet and outlet inverts /I Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N 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.): �! 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): 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Vol luntary.Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 City/Town State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Tight or Holding Tank(cunt.) 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.): tz _ 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.): N / 6, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments M See e Subsurface Sewage Disposal System Form C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Citylrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: (1)6'Radius, W/ est. 3 stone ❑ 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.): soil conditions normal, no signs of hydraulic failure, no evidence of ponding or damp soil, no lush vegetation, bottom of sas 8' below grade, liquid depth at time of inspection 3.5', stain line 6"below inlet invert. 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 L Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection 1,pr _ 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.): 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.): 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 cityrrown State Zip Code Baker 05/29/07 Owner's Name 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. W 110 Santult Newtown RD Marstons Mills, MA 02648 Rear of House B A Deck O 1 1000 Gallon H-10 O 2 Septic Tank A 1-27' B 1-24' 2-32' 2-29' 3-59' 3-55' 0 6' tR=6') Leachplt 3 110 Santuit Newtown Rd-T5 lnspection.doc•11/2004 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Citylrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Site Exam: Slope *j / L %1 Surface water tJ /4 Check cellar !leg Shallow wells 1i//j- Estimated depth to ground water: f y y" + Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: reviewed prior inspection ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed topographic map and water rsource map You must describe how you established the high ground water elevation: Reviewed prior system inspection done in 1997 by John Graci indicating 12'+to est high water, construction permit indicates test hole to 144"w/no mention of water, USGS topographic and water resource maps, google earth satelite map for nearest open water elevation in relation to sas location. 110 Santuit Newtown Rd-T5 Inspection.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 16 I jFb 15 018 10:39a Mike Hudson 508-775-7889 p,1 Commonwealth of Massachusetts Title 5 Official Inspection Form WE Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000. Inspection forms may not be altered in any way. A. Certification Important:When filling out forms 1. Property Information: on the computer, 110 Santuit Newtown Rd use only the tab � key to move your Property Address -, cursor-donor Martha'& Donald Baker use the return Owner's Name l -r t key. �—� 110 Santuit Newtown Rd a ' Owners Address M, Marstons Mills MA c 1 02648- 4 FACitylfow+n State �-� Z�Code- 2� Date of Inspection: 05/29/07 L w' Date n� 2. Inspector. Mike Hudson Name of Inspector Septic-Wiz Environmental Services Company iName 32 Midway Dr Company Address Centerville MA 02632 CityrTown state Zip Code 508-367-5669 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 CNIR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ N Furth Evaluation by the Local Approving Authority 06/11/07 In ors SlEgnatilre 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. 110 Santuit Newtown Rd-T5 Inspedion.doc-11/2004 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Ti Feb 15 08 10:40a Mike Hudson 508-775-7889 p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Farm A. Certification (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA C2648 City/Town state zip code Baker 05/29/07 Owner's Name Date of Inspection 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: The System passes by DEP standards at time of inspection however under an increased load the SAS has a limited life expectancy of not more than a few years. All effluent limits pass by DEP standards but recommend pumping system due to near required pumping levels. 1 r 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. ❑ 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: 110 Santuit Newtown Rd-T5 Inspection.doc•1112W Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System Page 2 of 16 Feb 15 08 10:40a Mike Hudson 508-775-7889 p.3 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cant.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 cityrrown State Zip Code Baker 05/29107 Owner's Name Date of Inspection N 1 _ B) System Conditionally Passes (cant.): 1 ❑ 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: ❑ 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: 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 110 Santurt Newtown Rd-T5 Inspection.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 f Feb 15 08 10:40a Mike Hudson 508-775-7889 p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (corn.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Citylrown State Tip code Baker 06/29/07 Owner's Name Date of Inspection �.� C) Further Evaluation is Required by the Board of Health (cunt.): 2. System will fail unless the Board of Health(and Public Water Supplier,d 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 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: 110 Santut Newtown Rd-T5 inspection.doc•11r2004 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System Page 4 of 16 Feb 15 08 10:41a Mike Hudson 508-775-7889 p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 110 Santuit Newtown Rd Property Address Marston Mills MA 02648 Cityfrown State ZipCode Baker 05/29/07 Owner's Name Date of Inspection 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 ❑ S Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ S Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surfaoe 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. ❑ S 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 ammonla 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 ❑ S 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. 110 Santuit Newtown Rd-T5 Inspection.doc•1112004 TWO 5 Official Ingx%don Form:Subsurface Sewage Disposal System Page 5 of 16 Feb 15 08 10:41a Mike Hudson 508-775-7889 p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cons.) 110 Santuit Newtown Rd Property Address Marston Mills MA 02648 CityJrown State Zip Code Baker 05/29/07 Owner's Name Date of Inspection 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. 110 Santuit Newtown Rd-T5 Inspection.doc-1112D04 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 6 of 16 Feb 15 08 10:42a Mike Hudson 508-775-7889 p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 110 Santuit Newtown Rd _. . Property Address Marstons Mills MA 02648 Cityfrown State Zip Code Baker _ 05/29/07 Owner's Name Date of Inspectfori Check if the following have been done. You crust 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 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? ® ❑ 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(3)(b)] 110 Santuit Newtown Rd-T5 Inspection.doc•1112004 Title 5 Official Inspection Form.Subsurface Sewage Disposal System- Page 7 of 16 Feb 15 08 10:42a Mike Hudson 508-775-7889 p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 110 Santuit Newtown rd Property Address Marston Mills MA 02648 City/rown state Zip Code Baker 05/29107 Owner's Name Date of Inspection Residential Flow Conditlion s: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2005-271 GPD 2006-210 GPD Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seatslpersonslsq.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: Last date of occupancyluse: Date Other(describe): 110 Santuit Newtown Rd-T5 Inspection.doc•1112004 Tftle 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 f Feb 15 08 10:42a Mike Hudson 508-775-7889 p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marston Mills MA 02648 cityrrown State Zip Code Baker 05/29107 owner's Name Date of Inspection General Information Pumping Records: Source of information: Water Pollution Control-last pumping on file 11/24/01 Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: n/a gallons How was quantity pumped determined? n/a Reason for pumping: nla 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) ❑ Innovabve/Altemative 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: 23 years, installed in 1984 via of construction permit on file at BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No 110 Santult Newtown Rd-TS Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 9 of 16 Feb 15 08 10:43a Mike Hudson 508-775-7889 p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cityrrown state Zip Code Baker 05/29107 Owner's Name Date of Inspection Building Sewer(kxcate on site plan): Depth below grade: 26 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 8'6'Lx4'10'Wx5'8"H- 1000 gallon Sludge depth: 4'8�hickness) Distance from bop of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" 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 16" How were dimensions determined? Measured stick w/hinge,tape, floodlight, mirror 110 Santul Newtown Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 10 of 16 Feb 15 08 10: 3a Mike Hudson 508-775-7889 p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 110 Santuit Newton Rd Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Baker 05/29/07 owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping every 36 months, inlet and outlet tee and baffle in good condition, tank appears structurally sound wf no evidence of leakage, effluent levels normal in relation to inlet and outlet inverts 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.): 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): 110 Santuit Newtown Rd-T5 Inspection.doc•11/2004 Tide 5 Offfioial Irgmction Form:Subsurface Sewage Disposal System Page 11 of 16 Feb 15 08 10:44a Mike Hudson 508-775-7889 p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Baker 05/29/07 owners Name Date of Inspection Tight or Holding Tank(cont.) 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.): Distribufion 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 110 Santuit Newtown Rd-T5 Inspection.doc- 1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Feb 15 08 10:44a Mike Hudson 508-775-7889 p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cityfrown State Zip Code Baker 05/29/07 Owners Name Date of Inspection Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: (1) 6'Radius, W/ est. 3 stone ❑ 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.): soil conditions normal, no signs of hydraulic failure, no evidence of ponding or damp soil, no lush vegetation, bottom of sas 8' below grade, liquid depth at time of inspection 3.5', stain line V below inlet invert. 110 Santuit Newtown Rd-T5 Inspectlon.doc-1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Feb 15 08 10:44a Mike Hudson 508-775-7889 p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 110 Santuit Newtown Rd Property Address Marstons Mills MA 02648 Cltyfrown state Zip Code Baiter 06129W Owner's Name Date of Inspection _ 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.): l _ 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.): 110 Santuit Newtown Rd-75 Inspection.doc-11/2004 Title 5 official Inspection Form:Subsurface Sewage Disposal System- Page 14 of 16 Feb 15 08 10:45a Mike Hudson 508-775-7889 p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Volu ntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 110 Santuit Newtown Rd Properly Address Marstons Mills MA 02648 City/Town state Zip Code Baker 05/29/07 Owner's Name 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 budding. W 110 Santult Newtown RD Marstons Mills, MA 02648 Rear of House B A Deck 1 1000 Galion H-10 2 Septic Tank A 1-27' B 1-24' 2-32, 2-29, 3-39' 3-55' 0 6' (R=61) Leachpit 3 110 Sanhdt Newbwn Rd-T5 inspection.doc-1112004 Title 5 OfrrcFal Inspection For., Subsurface Sewage Disposal System Page 15 of 16 Feb 15 08 10:45a Mike Hudson 508-775-7889 p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) 110 San tuit Newtown Rd Property Address Marstons Mills MA 02648 City/Town State Zip Code Baker 05/29/07 Owner's Name Date of Inspection Site Exam: Slope v\u s io,r e L r 1 Surface water N) Check cellar ✓ Shallow wells N j 4, Estimated depth to ground water: 1444 Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record ff checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: reviewed prior inspection ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed topographic map and water rsource map You must describe how you established the high ground water elevation: Reviewed prior system inspection done in 1997 by John Graci indicating 12'+to est high water, construction permit indicates test hole to 144"wl no mention of water, USGS topographic and water resource maps, google earth satelite map for nearest open water elevation in relation to sas location. 110 Sarduil Newtown Rd-T5 Inspection.doc-1112004 Tide 5 Oftial Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 No.��......._...... FE$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 94-'A�..............0 F.............��. . � 5% �� � - b 3 ► ' A p iration for Uiopoottl Workii Tontrnr#ion Errant Application is hereby made for a ermit to Construct (� Or Repair ( ) an Individual Sewage Disposal System at: . ._.......-. � o. ....------.........�..... ............................................................ ...••. Location-Address or Lot No. ,P:/�. �% r���.- P..... ��.. .................... 'UDC. (, �' .. �....... ••... ••. Owner Address , ff ..... ---------------- .. Ad 4nstaller dress d PQ Type of Building Size Lot. f,�-..7_.0./..Sq. feet U Dwelling—No. of Bedrooms...............-3-----------------------Expansion Attic Garbage Grinder ( — '� Other—Type of Building No. of persons............................ Showers Pr YP g -•--•-•-••-•-•-•----------•• P ( ) — Cafeteria ( ) 04 Other fixtures .........•••... -•----•--......- - W Design Flow.............. ._.____.._...gallons per person per day. Total daily flow.............. _ . .............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------• Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.... sq. ft. z Other Distribution box (/ Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ r] Test Pit No. 1... . Ss__minutes per inch Depth of Test Pit......./°„Depth to ground water------- r - Gi. Test Pit No. 2.._....�ye.minutes per inch Depth of.Test Pit.................... Depth to ground water........................ (P . xDescription of Soil !:::•r•;-----•----e4w-x-- ---------•-•-----------------------•---••-•------------------ U ---•••-•••-•-•-••••----••••-•••••••--•-••••••-••-•-••--•-•-•••-•...................•••--•••--------............................. - -= --- - --- VNature of Repairs or Alterations—Answer when applicable............................................................................................... ---••-.....•-•••------•••••••••--•-••••••-•••-••••--•-•••....................•-••-•-•-•••••-•-...............-•-••••-•---••••-•--•--•...--•••-......•-•--•-----•-•••---••-•-••••••••--•......_..••...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until,a Certificate of Compliance has been issued by the board o ealth. ed.•..._..... o.. '�._ t ApplicationApproved By........... ••• ••-•--•-•-•.................••----•._....•••••-••-•--•--••--••...-••••-•-•--•• f/d ._ LY--•..... Date Application Disapproved for he f lowing reasons: ...---•............._ ..--•-•---•----------•----•---•-••---•----•----•------•----...--••----•--•------•..........................•--....................••-----•-•••-•••-•••-•-------••••-••------- ----------••------------ Date PermitNo......................................................._ Issued....................................................... Date i NoPl _M___Lg_._-- Fmc�b..:............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... .....OIiLW OF.............. h ..................... Appliratiun for Uiupu,ial Work i Tunutrurtiun Prrutit Application is hereby m4dL for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: /' ................................................................................ ....... ...........................te........../...............Ak1,4_,.,.7q G/t 5 LpA-�ddr%sue c O� or Lot No* ......................_..• •••--•-�--.�'---------------------.....---- --- �`�� ........ 5_2-1�....... -_____ -- - ��wner Address f ..... .5 ---------------------------------------- Installer Address QType of Building Size Lot.�__.g.'7-0.1'___Sq. feet U Dwelling—No. of Bedrooms................5_......................Expansion Attic Garbage Grinder ( ' aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) G-I Other fixtures ...................................................... Design Flow................ ._______.___..gallons per person per day. Total daily flow__._.___._.__7�__.✓__.............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----_----_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (/ Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I._L�s.,5.1_.minutes per inch Depth of Test Pit....... '�.Depth to ground water_._._,/ 1��p Gi, Test Pit No. 2_______ ._minutes per inch Depth of Test Pit____________________ Depth to ground water........................ o -•----••-•._......--••----•--••---- — ' L r� .s S.'a4's.. x Description of Soil _ r- -----��•,!________--•------------------------------------------•----•----- ---------------------------------------•------------•------------....._.__...---...----------•---- /� .. - ..................... 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 TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board �ealthh�.. Date -- �Sg Application Approved By--•- •••••-----------------•--•-•-----------•-•-•-•----------------- . � r Application Disapproved for e f owing reasons----------------------------•----•----------------------------....--------------...._.._.._...---•--•----•---•-- -------------------•-•-•------•---•--•--.._..--•...•---•-•••-------------....•-•--------......._...._...._._._.._........-•••-•-••--••-------•----•----•--••--••-•••••--•---•----••-•••-••••----....._.. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... -U!^-/'` .........0F.............. /............................ (9rrfifiratr of Tnntplittnre THIS IS TO CERTIFY, That the Individual Sewa isposal System constructed (, ) or Repaired ( ) by....................................... �S•••-•--_••••� -=----•-------•----------•--•--------••-•--••---•-•---•_-••- -•...-... _. -•�- Installer 164 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 > ,,,_. dated..............:....... ................ THE ISSIJAN E OF THIS CERTIFICATE SHALL NOT BE CONSTRIDED A A E THAT THE SYSTEM Wl�k G FICTION SATISFACTORY. DATE...</ ...._._ Inspector...._ ..... ........................................................................... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD �OF HEALTH A�" ......OF......-....!7. _ � ....................... ........................ FEE........................ �iu�ruu�tl Turku ��unu#rnr#Uan �p�i� Permission is hereby granted.............................07 -!--1 Q C�t2 to Construct ( ') or Repair ( ) an Individual Sewage Disposal System �� �/ '/� at No......................................... -- ......t . ---�"� �.•---....6V'� �f''�y.' /!/I `'v G Street as shown on/theaplicati, for Disposal Works Construction Permit No____________ _______ Dated.......................................... = = ----••-•-••----•....._.._ c' Board of Health DATE...... -•--"- . ........................................ FORM 1255 A. M. SULKIN, INC., BOSTON Commonwealth of Massachusetts Executive Office of Enviroiuuental Affairs Dept. of Environmental Protection One winter Street, Boston,Ma. 02108 John Grad D.E.P. Title V Septic Inspector lug P.O. Box 2119 Teaticket,MA 02536 WILLIAM F.WELD (508) 564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I♦! \. J —f 1 ,9 PART A CERTIFICATION 3 Property Address: 110drtewteeu�Rd.Marstons Mills `-' Address of Owner: Date of Inspection:7/31197 (If different) l 8 ~ Name of Inspector: John Graci Blanchette 0,F ~ I am a DEP approved system inspector pursuant to Section 15.340 of Title%.(310 CMR 15.000) W�lB9q �`9`9J Company Name,Address and Telephone Number: CERTIFICATION STATEMENT �r ` I certify that I have personally inspected the sewage disposal system at this address and that the information reported be ow Is rue, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of howthe system is _ NeedjFhe Evaluation B the Local Approving Authority performing at the time of the inspection.My inspection does Y pP 9 ty not imply any warranty or guarantee of the longevity of the Fails septic system and any of its components useful life. Inspector's Signature: Date: 816197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04n7197) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection:7)31197 _ Sewaae backup or.breakout.or high.static water level observed.in.the distrihution box is due to a broken. or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D) SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ i have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection:7/31/97 D] SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must.indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection:7/31/97 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _X_ — Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with NIA. X — The facility or dwelling was inspected for signs of sewage back-up. X — The system does not receive non-sanitary or industrial waste flow. _y_ — The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. X _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. X Existing information. Ex. Plan at B.O.H. X Determined in the field(If any failure criteria related to Part C is at issue, approximation of distance is unacceptable)]15.302(3)(b)] (revised 04127/97) l - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection:7/31/97 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bed room for S.A.S. Number of bedrooms. 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): n/a Sump Pump(yes or no): No Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: n/a Last date of occupancy: n/o OTHER: (Describe) n/a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance. TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 1985 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection:7/31/97 SEPTIC TANK: x (locate on site plan) Depth below grade: B" Material of construction:X concreate metal_FRP_Polyethylene_other(explain) If tank is metal, list age 12 . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L B'6"H 5'7"W 4'10' Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness:5" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined: Measured 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.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:We Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping,va 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.) n/a BUILDING SEWER: (Locate on site plan) Depth below grade: 14" Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line:town Diameter: 4'_ tn/amments:(conditions of joints,venting, evidence of leakage,etc.) (revised 04127/97) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection:7/31/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: We Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n/a Capacity: n/a gallons Design flow: We gallons/day Alarm level:_nja Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) n/e DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) n/a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a (revised 04/27197) v , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection:7/31/97 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: Nfl Type: leaching pits,number: 1000 gallon leach pits leaching chambers,number:n/a leaching galleries, number: n/a leaching trenches,number, length: We leaching fields, number,dimensions:n/a overflow cesspool, number:n/a Alternate system: n/a Name of Technology:_nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The overflow is structurally sound and functioning properly.lt was 1/2 full at the time of the inspection. CESSPOOLS:_ (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: nla Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) n/a 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 (revised 04/27/97) •� i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection: 7/31/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) kf d A g �� 3J (revised 04127/97) page 0 of 10 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Newtown Rd.Marstons Mills Owner: Blanchette Date of Inspection: 7r31r97 Depth to Groundwater 12+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc. Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (MUST be completed) USGS Maps and Charts (revised 04/27/97) page 10 of 10 t ¢. �^. r yy .4J. PIN r fit: x e� r+ye t �'j�f'/jrOl<• LAC-r(f«" 4 i f •r•1 t 1 J ( fr Z—l7 N !N✓ i'. !�u ST I3� F f K' r' v c, 2. 1 7 1 !G c - " AO 0IV - r J r y 1000 'k ,f r Y 151 LEGEND icrh CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION Ox0 ia,. EXISTING CONTOUR ---- 0 ——— _��� ''a� � L.dT G 5,ej- , FINISHED SPOT ELEVATIONo A a �; :'�" fie �'= FINISHED CONTOUR 0 � R' /�'I�3 `' r_f ���,./ ORSE �, I NNo.10951 APPROVED , BOARD OF HEALTH Ayo�'Fc,sTEg���� FSSIONAI Eat r- DATE AGENT SCALE, � DATE , a/ 3 /r:51v. CC2 n Ri ? �;4t Gr A� . CELOREDGE ENGINEERING Co' IN CLIENT ,�� `° I CERTIFY THAT THE PROPOSED a* _ +�+�— Sys ROBERT �,� LL�: EGISTERE REGISTERED 3 z-6 4 - ekucE BUILDING SHOWN ON THIS PLAN V3 CIVIL LAND JOB N0, , �,.� ELDRE �' CONFORMS TO THE ZONING LAWS ca DR BY, OF �s►'f�n/sar�t�t �: MASS. ENGINEER URV Y ? �t� �y 712 MAIN STREET CH..8Y� 3 NYANNIS, MASS. REG. LAND SU SHEET.._.OF �.._. OA E RVEYOR