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Home My WebLink About0737 SANTUIT-NEWTOWN ROAD - Health A= 028 010 - - y i i 0 , y Commonwealth of Massachusetts Title 5 official Inspection Form ' rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 737 Santuit Newtown Rd Property Address �+ Phyllis Whitney F,f Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 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. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5-16-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form F�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1r_ ;> 737 Santuit Newtown Rd Property Address Phyllis WhitneyY Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System-,Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "Co nditionalPass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts .i ;w^, Title 5 Official Inspection Form ,I5"i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' a 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ON ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. ' a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form *I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No El Backup of sewage into facility or system component due to overloaded or ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form } <•��i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria-exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form nI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? , ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, ,depth of liquid, depth of sludge and depth of scum? p q p 9 ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No .Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5-2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts r� y Title 5 Official Inspection Form r�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner----pumped 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance _ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rc_ ;> 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 72"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.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I f s Commonwealth of Massachusetts r� Title 5 Official Inspection Form i�� ,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 60"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: 1500 gal H-20 Sludge depth: T Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness Distance from top of scum to top of outlet tee or baffle 1. 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons i Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 I ., Commonwealth of Massachusetts t6 �. a ,pp Title 5 Official Inspection Form �.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts .jI. ;w Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �< -,_• ,;>" 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3-Flodiffusers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;Z;P 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 .5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Flodiffuser field in good working order with water level and stain line at 50% capacity. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p : r y 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - =w" 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Y rb j t " 7 t J.0 mp a tr 4r I� � � �r_� � .�4 r� r j a r Ll-1 ryas l'ne t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Fora M Subsurface Sewage Disposal System Form -Not for Voluntary„r rY Assessments 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at about 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 1 Commonwealth of Massachusetts r� Title 5 Official Inspection Form } �I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 737 Santuit Newtown Rd Property Address Phyllis Whitney Owner Owner's Name information is required for every Marstons Mills MA 02648 5-16-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 . I FFe 9 199 -~ BORTOLOTTI CONSTRUCTION, INC. -- 70-VAKEBY`ROAD,'MARST0NS MILLS, MA 02648 5118=771-9399 508428'8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: `737 /V &_)6&)/) gd at-skas Date of Inspection: 9 q Inspector's Name: 171 / er's Name and Address: /�n p�`p / 73� r�d� /ls _ CERTIFICATION 4TAT M NT• I'certify that I have personally inspected the.sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of(fie time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Pas Needs Further v ,nation y. Local Apr' ving Authority Fails Inspector's Signature: Date: The System Inspector shall.sub t a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION STIMMARY: A)SYST') [PASSES: ✓ I have not found any information which indicates that the system violates aqY of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the.replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked, structurally unsound,'shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The+Hoard of Health. Sewage backkup or breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - • f SUBSURFACE SEWAGE DISPOSAL Sys'l'EM.,1.N.SPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed , Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass.inspection if(with approval of The Board of Health): Broken pipes)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 PRO'irECT THE PUBLIC HEALTH AND SAFETY AND_THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50.Feet of a bordering vegetated wetland or.a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND,PUBLIC WATER SUPPLIER,IF APPROPRIATE).DETERMINES THAT THE SYSTEM IS FUNCTION- ,.ING INA'MANNER THAT PROTECT.THE PUBLIC.HEALTH AND SAFETY AND THE The system-has a septic tank and soii,ibsorption system and Tis within 100 Feet to a surface water supply outributary-6 a surface water supply.,.,., •, , The system has a septic tank and soil absorption system and is mith a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm: _. - _ , . } D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15:303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of We ground or surface waters due to an overloaded or clogged SAS or cesspool. ., Static liquid level in the'distribution box above outlet invertAue to an overloaded or clog- p ged SAS or cesspool t ' Liquid depth''i'n'cesspool'is less than 6",below invert or.available volume is less than 1/2 day flow. 'S}n:; Required`pump'ing'more'th, - 4�times in'the la*Cyear.NOT due to clogged or obstructed pipe(s).'Number of times pumped -2- I i SUBSt1RFACE SEWAGE b1SPOSA71 L SYSTEM'INSPECTION FORM PART A CERTIFICATION (cowinucd) 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. i Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the-system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of if surface drinking water-supply "Thesystem Wwithin`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 I1 of a public water°supply welt: The owner or operator of any such system''shall bring the"system.and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ping information was requested of the owner,occupant,and Board of Hhalth. None of the system components have been pumped for atleast two weeks and the system has ,been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ---,_/As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 7he system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. . s��,..All system components,excluding the Soil Absorption System,.have been located on site. =The septic tank manholes were uncovered, 'opened,.,and the interior:of.the septic tank was in- spected for condition of baffles or tees,material,of construction,dimensions,.depth of liquid, %depth of sludge,depth of scum. ; r I/The size and location of the Soil.Absorption System;on.the site has been determined based on existing information or approximated by non-intrusive methods. -3 ,k f• _ i 0: i , • fag r.; Y,'..a s Y:t';f.... � . .q - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART B CHECKLIST(continued) provided information on The facili owner(and,occupants,ants if different from owner were ov ded wi the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION:-- FLOW CONDITIONS RF.SII)ENTIAL: Design Flow: 3,.30 allons Number of Bedrooms: Num Res bcr of Current idents: Garbage Grinder: Laundry Connected To System: Seasonal Use: U Water Meter Rea di gs,if fable: Last Date of Occupancy: "s i c)e,-xc e CONIMFRCIAIJLNDIISTRIAI Type of Establishment: "Design Flow: aallor sgday Grease Tra Present: es or_no n _.. Industrial.Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings; If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part-of inspection: If yes,volume pu gallons Reason for pumping: TYP*F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single.Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): A(PgROXIMATE AGEn of all mponen ;date installe f known ..and source of information:,' Sewage odors detected when arriving at the site: �> �. -4- i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "'',GENERAL INFORMATION (continued) SEPTIC TANK: v Depth below grade:? r Material of Constriction: ✓concrete ''metal FRP Other (explain), — Dimisions: /O.S X�i�"�'S� Sludge Depth: Scum Thic ne.ss: " Distance from top of sludge to bottom of outlet tee or baffle: 3 S Distance from bottom of scum to bottom of outlet tee or baffle:-- Comments: (recommendation for pumping,condition of inlet and outlet tees or balnes,depth of liquid level in relation t outlet rnGert sirucCtiral integrit evidence of lea k4 a etc.) �5 Q /SZX� yr,e l use GREASE TRAP: Depth Below Grade: Material of Constntcti ow concrete metal FItP Other (explain) — — — Dimensions: Scum Thickness: " Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet;tees or—baffles— depth'of'liquid level in relation to outlet invert, structural integrity, evidence.of-lenk�ge,,etc'.') TIGHT OR HOLDING TANK: Ad Depth Below Grade: Material of Construction:__concrete_metal_FRP-Other(explain) Dimensions: Capacitv: gallons Design Floiv- gallons/day Alarm Level: __ Comments: (condition of inlet tee, condition of alarm and (loaf switches, etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note' 1 el and distribution is equal„evidence of solids carryover, evidence of leakage int°/ or out of box,etc.) o��, n .�d Osc � ) PUMP CHAMBER: Comments: (note condition of pump cltjmber condition of p�ttnps oriel=appurtenances;etc}` _ _ f I SU1BS RFA`F 3 U CE SEWAGE'DISPOSAL•SYS TEM INSPECTION FORM .. : PART C SYSTEWINFORMATION (con(inued) SOIL ABSORPTION SYSTEM(SAS): y (Locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number: leaching chambers, number: Leachinggaileries,number: Leaching trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool,number: Comme ts: (note condition of soi si ns of hydraulic failure level of pondin condition of vegetation, etc.) �� / r e 4O t�v7 ro CESSPOOLS: /`w , Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: -r Depth of scum layer: Dimensions of Cesspool: Materials of construction: indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- A ;:;SUBSURFACE SEWAGE;DISPOSAL,SYSTEM-INSPECTIONFORM PART C SYSTEM-INFORMATION(continued) . SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. a16 DEPTH TO GROUNDWATER: Depth to groundwater: Feet / ,� M od of�nnina 'on or Approximation: �X� G' ` ��' �'S �'� 51, 141i .5 TGWI(Old BARtNSTABLE LOCAr0N VILLA� S s 1 S p,�SESSOn MAP�c L INSTAU.M NAM-B&PHONE NO. 7777 SIcC WANK CAPA LIILPTG I�ACIILI'FY:.i�Ypa) �1° ts�ze) a: �1O OFS S PERMIT112A' O17NQsC.Il4AiGE D/4'[E..w.::. ..;ram. S patwtco► woo Batviesa� NiaximuniAdjustedGrcwadwaterFabletotheBottomof eachin suiUty.. Feet q� 64IC��5 C7CIS� bll Wid Lego a r rr+►ja� r �� y . Boolf att sett of w two?AO feat ol?:l+acfat�► f )`. Ba and exist v yetic o mw . P+ee ., n a�sin acili r ��O fce` la�r:1� BOA f ►30 fz 545 fine 1�e R un5 61.5 TOWN OF BARNSTABLE LOCATIONOjV- � jij�/y�� SEWAGE # VILLAGER'OZ f 6aS /J/�/S ASSESSOR'S MAP & LOT 6Q=0)0 INSTALLER'S NAME & PHONE NO(&1`k16Y1jej0J1 SEPTIC TANK CAPACITY r LEACHING FACILITY:(type)� NO. OF BEDROOMS PRIVATE WELL PUBLIC WATER BUILDER OWN _��o? e 9' DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: o -?-Y VARIANCE GRANTED: Yes r �zQ u-r—o—� �a-�� ,� a .. y,7� � Sr L / ��o No... FIms.........tl ram ..../ THE COMMONWEALTH OF MASSACHUSETTS / P 7 3t1 g BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiuii for Di;ipimal Works atuitrurtiun Vamit Application is hereby made for a Permit to Construct ( " or Repair ( ) an Individual Sewage Disposal System-,at: ....................•- �.•. •--•- �-----•---•-----•--�....._._.....s ..................................................... l -......-••••-- Location-Address p — or Lot No. ........... ...... ___...- - - 11---------------•- -•---------•----.._------- ._..----.......-_......_......._.......-- A. owner Address W I its tat Ier Address q 7 Type of Building Size Lot.... _/-l. .Sq. feet ., Dwelling—No. of Bedrooms........___________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons......................------ Showers ( ) Cafeteria ( ) a Other fi t es -------------------------------- .. Ions. -------- - - W Design Flow______________________________________ gallons per person per day. Total dvil rflow---_._ gal Ra Septic Tank—Liquid ca acit -�-?. allons Len tli. __ Widt _... Diameter................ De th___ P 9 P - g r g ,�--------- Disposal Trench-- No. .--.e............ Width_`a._._..._.. Total Length.................... Total leaching area.. • 3 Seepage Pit No..................... Diameter.................... Depth below inlet.........._......... Total_leaching area. z Other Distribution box Dosing tank ( ) Percolation Test Results Performed ..._O�C___._._ Date___ ____z.7/_ _,9_-. 6 a Test Pit No. I-_�_Z-minutes per inch Depth of Test Pith..-,' Depth to groun water_ ' �?........ LZ4 Test Pit No. 2.."'.`.`_. minutes per inch Depth of Test Pitt ------- Depth to ground04 -------------------------•-••-•-•-•-----•------••-•-•••-•-•••--••••---_._...__.._..._....--•------ Description of Soil �� --•--� ��....._--V----Z ` ........................................................... x W --- --•---•------------------------•--------------------------.......-----------._..--------------------------------------•------------•---------------...--------------------•-••-••-•••--••--•---•- UNature 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 Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h.a. b�e y t board of health. Signed><....... ........................................................... ..... Dace .-�..-...-1- �.Dve APPlication APProvedB 1 Y ........... ...... Application Disapproved for the following reasons: ....._......................_..........------.......-....-...-..--.._-.-_ ... .............. ................................. ..................... . ........................................... . ..................--. .-.......-....................... ........................................ O� Dare PermitNo. Ll �.............................. Issued ................. ............................................ Dare Fas.......... C'?.a.... THE COMMONWEALTH OF MASSACHUSETTS / P 7.3 y BOARD OF HEALTH TOWN OF BARNSTABLE ,c ppliration for DiripwiMl Morks Tonitrnrtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: . . !c J/,� ..y/c,,,f . n lS /�...... fjLocation-:\ddmss -----••----..---••------------------------or Lot No: ..............:�!'![.M.:.......�p o <_. _C?-------•-------•---- ---....---.........--------••--......-•-- Own r Address W Installer Address �1 q 'I l Type of Building 3 Size Lot___/. ./_ .Sq. feet Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixt es --------------------•---•------•--•-•--•--•......••----•--••......---..........---•-•-- -•--------•- W Design Flow.................. .....................gallons per person per day. Total daily,flow_..... ?.�- .._. ................gallons. WSeptic Tank—Liquid capacit/ -,5.0.gallons Length_ .... Widt�__-____ Diameter................ De th_-�-_...._ . .._... Width.Zo..._...... .Total Length.................... Total leaching area.... .No. ` �,0.' 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area...............-.sq. ft Z Other Distribution box (vim}'` Dosing tank a Percolation Test Results Performed by.. .. ._..... ..._._. Date... `�,l `! Test Pit No. 1._ '.2-_minutes per inch Depth of Test Pit�-�--_--_`__ Depth to ground water.rV:AA—J IF LL, Test Pit No. 2..:77S..Zminutes per inch Depth of Test Pit 2_d...... Depth to ground ---------•-------------------------•............-•-•••......• --............... ..... • ......................................................... 0 Description of Soil.......... �J?h`"'.. �� =��-9 ......................................................... x ••••-•-••••••---------•...---------•--•-•--•----•- ..... x ..................•-..... 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 TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance/hasbe n issued,py t el board of health. dSi ne g� . . -(- /fi ....Da C i Application Approved By ------ -----0 s4 �-.-.=,..,� ................. ..- _......`...ti Application Disapproved for the following reason : :........................................................................................................................... i - � Dace Permit No. ! c-l.--:. 06---------------- Issued ........................................................_.......... ........................ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 'ClErtifi atr of Tompliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by ........................----- --- _--------------------- a....ef - .........................-....._...._............................ .......- ...h,�: at ...........�n ..v�-......_ :Za ......._jl/2Gc `-v*�-ram.. ►` ....-.1M-,.-l�l..........1��. ..... �;............. has been installed in accordance with the provisions of TITLE 5-of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... - - - . C>. dated _...... ...................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. (� DATE...... ............. _-...J...4...-?—/...........--_ -------------------- -- Inspector ------------- � ....:................................................... ----------------- -------- --_------__--------------------------__----------� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C— 3 FEE... .f.!......... Dish owd Workii Tomitrudion "prrmit - Permissionis hereby granted------------------------------------•------•-------------------------------------•-----------------------•----------•------••-----..-•------- to Construct O or Repair ( ) an Individual Sewage Disposal System T Z....... � -- - --Ill P- - Street qq as shown on the application for Disposal Works Construction Permit No.l.f__. -_ Dated........ -"J? ........... ----•----•-•-•••---•••------••-•-•-•••-• ---- ...................................... - DATE...........7.-- --F q .oarU of Health y..----•................................... FORM 36508 HOBBS ak WARREN.INC..PUBLISHERS 72. . N�'a _-- -'-_ ��— ..._-'' -�--�` �—__-� .._.__ --- -_.._ -- � ._ 70 _� �.1��less:3 � ►uc 42M MO' O• all o78.0 , 44 ,I: s� 1 Q ; � e / a a ,�( l0 4po- E604fl�> y I 1 \ �c • 15oo G441.., p�' �. sE1c�-ro,rJ1L / toy "ol f-.,�,� Ia of.sTdr. to I 3a C>4 _ — _-------�-----`"--- f--- � fi T T LA4� a Sk. 130,00 .110 1. ALL S OLV-TavM Tcl W,. A-Zo Lcbvt5J 1Z, IZAISE �-- �IT�N 1z"oF irJls*�G�►�� f Of DANIEL S OFBRAM EE Ai CIVIL V N..32606 C 07 up1AR M�'`-yG"0 � /ST (i N0,35791 o�fSS/ONAL 1 ( r�C ,yN FSSIO � �Jt/!��-t-e. 1' •� . �� L►1 W J Iv�IY �, _ 4c� Rom/ NA i o,M4-- i2e,/, t-4 `f z+,t99 4�- gox CScS�,3Co2 8131