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HomeMy WebLinkAbout0078 SAWMILL ROAD - Health 78 Sawmill Road Marstons Mills A = 063 — 065 S M E A DR No. 2-153LY UPC 12934 smead.com • Made in USA ��crcuo J c�i a s "I h� ��?lrciiNSJ"• SUS IAINABLE FORESTRY INITIATIVE Certified Fiber Sourcing www.sfiprogram.org i����r�-���� r-� �� �,�08 � 33 �6/� � �' �c��� � Crr�? �,1✓n-c,e, I - Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 y Property Address Donna Friedman et als. Owner Owner's Name •. information is required for every Marstons Mills MA 02648 November 9, 2015 � page. City/Town State Zip Code Date of Inspection �. r�..y 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 filling out forms A. General Information on the computer, �J use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response �y Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes I -10OF41gSS ❑ Conditionally Passes ❑ Fails • _w�� DAVID ❑ Needs Filter Eva`)uation a Local Approving Authority COUGHANO R N � 0.1 8 9p O T P _ November 9, 2015 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 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. r`( �Py.�6jV' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required,for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown 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: . Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage grinder is,recommended` B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. ,T The septic tank is metal and over 20 years old*orahe septic tank,(,whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltiation or tank failur&,is imminent. System will pass inspection if the existing tank is replaced with a'complyingseptic,tarik as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally-sound,tnot leaking and if a Certificate of Compliance indicating that the tank is less than 20�years old-is,available ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form ai Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 'obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts ti, W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9 2015 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 presence4of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other,r'failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9 2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia In and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑' Was the site inspected fbr signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): see below t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Original design plan calls for a three bedroom house, but provided flow capacity sufficient for five bedrooms. [5 bedrooms x 110 gal/day= 550 gal/day] -Septic tank capacity= 1500 gallons, two leach pits can handle 850 gal/day [Source: Site plan by Down Cape Engineering on file at Barnstable Town Offices] Assessor's website lists property as having 5 bedrooms. Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? . . 11 ® Yes ❑ No Water meter readings, if available last 2 ears usage 285 gpd 9 ( Y 9 (gpd)) Detail: 2014:95,000 gallons 2015:113,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: summer, 2015 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is Marstons Mills MA 02648 November 9, 2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner's agent Was system pumped as part'bf the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 33+ years. Certificate of Compliance for a new system was issued 3/4/1982 (Permit#82-82 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet s Comments (on condition of joints, venting, evidence of leakage,etc.):. Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 x 5 x 6-1500 gallon Sludge depth: 3 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: - ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is Marstons Mills MA 02648 November 9 2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at 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.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et a°s. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leach pits. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately MYSTIC LAKE L O C A ToONS THIS SKETCH IS �V BEST VIEWED IN —OF SEPTIC COMPONENTS COLOR FORMAT —DISTANCES IN DECIMAL FEET A B 1 20 . 25 2 26 32 3 22.5 29 LEACH LEACH PIT PIT 8 '3 nnnp , DISTRIBUTION BOX EX9STIG DWEL UNIG 1500 GALLON 1 F2i SEPTIC TANK Aor o�r� NOT LLI TO SCALE •• \�9j\ \�Y\ 508 364-0894 SAWM§LL ROAD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25+ 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: 3/1/1982Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: EJ Checked with local excavators,-installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system is over 10 feet above the elevation of Mystic Lake. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65 Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System 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 GEOHYDROLOGICAL PROFILE — NOT TO SCALE LEACHING PIT BOTTOM OF 41 LEACHING IS LEACHI NG ABOVE HIGH 0 GROUNDWATER ELEVATION OF ADJACENT POND t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ;-- .•tee t'.� ` - `�'• y's••S Y 7: ' ' i KID, Xv • '-' in, r ; / J �,'rf r r ! + s � � r���r/ / �ter`^•�.. — �— � � ly } ' �. i• fir. „ �. � ` ��`"`��—._� �.�� ` �' �—r.•....,_ �� ` l.C�. �{'" �---�DISTANCE AS CE T1F 69 HEFiEBY'QEt3T1i Y ,KAr. x&iLojh -- SITE PLAN I .;ttOWN ON THI$'PLAN'19 t'O O THE GAOVND AS SNO.WN HERE LOCUS. `��� -•r` �f' �� "' GNtARM 7p"THE ZONfN�C t3 WS THE TOWN OF • �d�-�Ftd C+ A1STRlfC7E0 ' A7�._,__�. _ r ,�. � s i { . REF: dGWR Cope engln4�!'�lll�' PREPARED Foy: CIVIL ENGINEERS SECTION - SEWAGE SEPTIC TANK _ .,D::sox LEACH TOP OF FON •Q (MSL)w ,.1211 OF IJSTO shl;- NOTE: wASHEO STONE RCMOVE;ANY UNSVITABLE'MATERIAL FOR A DISTANCE., OF 20 FT.AROUND ENTIRE LEACH AND REPLACE WITH CLEAN COARSE SANO.; I OUT IN OUT IN'• 1 =TA OUT- IN.0HLEV: EL EV. ELEv. ELEV. • �mt. n,•,t . -NOTE: �_ Gal.0+ l..:OF% 39j, BRING ALL COVERS TO WITHIN WASHED.STONE I FT:OF FIN►SH GRAOE. E1Co. TEST HOLE LOG TV-1 TEST BY Tte, ��3. 81 „� TEST OAT E L WITNESS DESIGN BEDROCK!:HOU: T-H• �► 2 I T.H. a 1 � ' .fit ELEV. •-a°' ELEV. r / FERG DATE ''-�� MIN/IN. OISPOSER DISPOSER FLOW RATE 3SO (GALJOAY) '3'3cs z.' _ -,i•"a 4 3i' .. .� r . �,�,z�, 4-�`ems .*r .., SEPTIC TANK 330 (I:y)'+ REQ'D SEPTIC TANK SIZE I SQ ra r�w to.:4Q LEACH FACILITY c:� li:*-SF- SIDE WAl.l_.(g�L����'��Is�sq�A 12.5 ) � 315 G/D. ..5.m AID, _ ,. ... BOTTOM ...� ten.. G/D TOTAL z•aa eft-4. e 4zS' c�r�i USE::.. LEACHING g C4�w..�.a• I� �.1ist•�+.� Cam' � r.�e•It1". 10 WATER.ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) , 3.DATUM(MSL)t TAKEN FROM S� .Qrr.r�� i OVAPRANGLE'MAP 2.MUNICIPALWATER ••„�•ib�!" _.. ,......._AV/4ILA9L£ ,g� �- 3.PIPE PI TCIi.W1 PER FOOT :t r•'t N t w%1 m i • ;' p '�� a.DESIGN LOADING FOR ALL PREmCAST UNITS:AASHO . •4a > S.MIN..GROUND COVEW OVER ALL SEWAGE FACILITIES:III FT. 6.PIPE JOINTS.SHALL BE MALE WATER TIGHT jl s F"` 7.CONSTRUCTION DETAILS TO BE ACCOROANCE WITH COMM.OF MASS. STA'YE Er4V.:I.RONMENTAL CODE Ti.TLE 5 I q. G.p nmZ. 1 REG,PROFESSIONAL CNG'IN Assessing As-Built Cards Page 1 of 2 'ae� 2 `Z2 L0 �ATION R� SEWAGE PERMIT NO. a �+ VILLAGE 411 J INSTALLER'S NAME A ADDRESS JOHN A. AA I l l J.: ,'.. cY' West Barnstable, Mass. 02668 5UIL0ER OR OWNER J J' DATE PERMIT ISSUED .._� � pZ DATE COMPLIANCE ISSUED 73, � 3 � How ix j http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=063065&seq=1 12/29/2015 3 F7 L0CAT10N SEWAGE PERMIT WO• VILLAGE ��ys t�is 4V A INSTA LLER'S NAME 8 ADDAESS JOHN A. AALTO B:^—,CKHOc SER'ViCE WC, i 1. '.i West Barnstable, Mass. 02668 IBUILDER OR OWNER oil GATE PERMIT ISS-V. EO D-ATE CO-MPLIANCE ISSUED j �� IT 40t A' -3 8 7 ' t"ll � � 1 i X Gb _ r r A ' r N .... ....... • �............... r �2 a� L F $ THE COMMONWEALTH OF MASSACHUSETTS BOARD-,P.. F HEALTH _ N.............OF.....� -1 --------- A pptira titan for Bhgpvii al lgjarkii Tonstrnrtuan Prrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: o tion-A ress or No ....... -k .4 � o .._. t.l �f cA.z m 1( �alk. ......._._ O er ress w a �� .._z r_� -- Mo.r�:../ c r ------------------------------------------- ,� Installer Address �\ U Type of Building 22 Size Lotj%.-�- .....Sq. feet — Dwelling—No. of Bedrooms.__..._...%3%3............................. Attic ( ) Garbage Grinder ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------- -----•-----•----•-•--------.••... -- W Design Flow.......... 5..........................gallons per person peroday. Total daily flow.._........_:3_-h�--------•-------_-•-•._gallons. 04 Septic Tank—Liquid capacity]5(Z.gallons Length.i��_��___...._ Width J`�.l....... Diameter................ Depth.5o3...__. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------Z......_---- Diameter......k.._.------ Depth below inlet......&.......... Total leaching area......sq. ft. z Other Distribution box ( ) Dosin"ank // Percolation.Test Result Performed b ._--ff-�__F�J(2E� 1�...fr .._ Date.._...Or .�y.. Y rt---------------- 1 , Test Pit No. 1__________------minutes per inch Depth of Test Pit.._.__ ��..... Depth to ground water......�P__...I---------- (y Test Pit No. 2.....2.......minutes per inch Depth of Test Pit..t`?Y ._... Depth to ground water-----&4........_... Pds .. .......................... O Descriptio of Soil 6....-- -----------------------•-•---- W -----•-----------------••------•-----•----•-•-•--••---•----•---•----•----------------•--------•-----------••-••-----•---------•----•-------- --•----••-•-••-••••-•----•--•-•--•-•-••-•-•-----------•---- ti x �t 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 I i `:_ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Ve issued by the board f heal, ned. -----••--•-••----a. ........ .....................•-•......-• -----� b..�_�� Date ApplicationApproved By....... ---- -----------•-•------------------------••-----•---------------- ---�•—.............................. Date Application Disapproved f o the owing reasons: ---- ---------------••--------------------------•----------------------.....-••-••-•------•._.........._ ---------------------------------•-•-----•--•------.......--•----•---- •----------------•--•------.....-----------•••--•--------------••---------••••---•-•---•-•-•----••------••-•-••-•-••------------- Date PermitNo......................................................... IssuedL....................................................... Date I owl No......................... nz.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF HEALTH �. I c ooL...... OF... �. �.1.{ L ... Aliv irFa#iaan for Bhipog al Workii Towitrnrtinn Prrutit Application is hereby made for a Permit to Construct ()) or Repair ( ) an Individual Sewage DisposalSystem at: -- --.......• --- .. . o tion-Address or No: � a& �Yj Q e t , r-f-Z n-� / .__ _.......... ---- - -...-----•.....................••---.--- :... ..------..................__--.•-- O er �cdress w ®d y...._....16.1)9 .1r--------------------------------- ---------�__.0.6 ..Y�:...11 5 Installer Address Q Type of Building Size Lot........_J� ._....Sq. feet V _Dwelhn '�io. of Bedrooms____.. ___. Ex ansion Attic Garba e Grinder oo _. .. _ ._ Other—TT of Bulldiu P I yP ' g No. of persons- Showers ( ) — Cafeteria Pa Other fi tures .....••-••--•••-•-••------------ W Design Flow.......... per person per�day. Total daily flow____-_._.___5_� .______._____________gallons. WSeptic Tank—Liquid capacityZ5(-*_gallons Length Widthf!_r__.____ Diameter________________ Depth;5;3..-.-. x Disposal Trench—No_____________________ Width___,_____.__.___.___ Total Length...__.______.._-__ Total leaching area....................sq. ft. Seepage Pit No...___.2.._____.._. Diameter....... Depth below inlet____.___._._._. Total leaching area�.....sq. ft. Z Other Distribution box ( ) Dosing_ank• ( ) '-' Percolation Test Results Performed by._. �._1"f�ttcl3✓aa�_... _r._.__ Date__.___ 3� r_ a --------------------- -------- a Test Pit No. I...... ______minutes per inch Depth of Test Pit._ -��______.__.__ Depth to ground water______�;_________- ri, Test Pit No. 2................minutes per inch Depth of Test Pit.. ................ Depth to ground water.... ............ O Descriptio of Soil SI l� c�l .._ ....1 � G" 616,U t C 6Q,'.� 6CAA C................................. a'` c} --- --- U -------------` �I u Q(cV�l -.. v----l -/'3, r :•-----._...•-- - •----•--•--•.........:.....• W ---------------------- ---------------------=----------=-------------------------------------------------------------------------------------------------------------------------------•-•----•---.--- 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 T. .-T:1'!I OJT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee sued by the.boar f hea ..ci.,F .. � ....- - _ •,n ..._ .. r.w. �f'iJ ►.mot'•`^. 1 �sr, .. . . . gned -- . . ....... ................ '�.. .. `...I -------- ----- Application Approved By. •- ------ --------- .. '-�6 .-- �'- ------------------------------------ ---- j Date Application Disapproved f the ollowing reasons:----------•-----•••••••••--••-•-----•---------------------------------------------------•--••---------------•--- --------•-•---------------•-----------------------------------------------•--•------------------------------------------------------.-.---------------------------------•.•----------------------------- Date PermitNo......................................................... Issued........_.............................................. Date THE COMMONWEALTH OF. MASSACHUSETTS BOAR OF H. A /. ........................OF.. .; .................. ................. :._.............. 1 TrrtifirFa#r ,a Rana THI . CE RTIFY, Tha the Indivi w e is al System constructed ( r Repaired ( ) by .. Installer. �f has been inst7alled in accordanc with the provisions of T �L r of The State Sanitar Co escribed in the application for Disposal Works Construction Permit No._ a_ _~_._.-_:____._.__ dates_. ... _____________________ 1_ :71- THE-ISSUANCE OF`Tia1S CERtIFICATE Sh1AL•L..NOT B,,CONSTRIJED AS XGUARANTEE THAT THE SYSTEM '1AIIU FUNCTION.SAT1SFk6T0RY1 DATE ---- ` �2".....---•--...---�------• 3>r Inspector 16 ��/�_�-_ , ............................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF TH �. No.............. ;• FE .................... i �rv� t1 ffpgronstrudion antiPermission a t e ranted-- -----------�------ ----- ------------ ---------------------------•---............................................... to Construct f( ) it �n Indio ual Sevcra sp al ystem at No..-- -- -------- -- ....... { Street �xz'as shown, the application for Disposal Works Construction Permit No.... Dated.______._.._ ............................ • Board of Health DATE---' FORM 1255 HOBBS & WARREN, INC., PUBLISHERS r Commonwealth of Massachusetts 0&3^0&6 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65-(REV04S€D T-G-S- 01N-3_'BEDRO__0 MS- Property Address Donna Friedman et als. 46 Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 31 page. City/Town State Zip Code Date of Inspection N 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response G Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ®- Passes, ❑ Conditionally Passes ❑ Fails - OSAOF&fq 'qC ElNeeds F Enwatio a Local Approving Authority o D. COUG 0 R u) N . 103 c el $::� f IREUI:SE----AAarch=30;20�� Inspector's Sign a /STE Date SgNITAR�t`N The system inspe 'a - _ bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP:The original should be sent to the-system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address " Donna Friedman et als. 'Owner Owner's Name information is equired for every Marstons Mills MA 02648 November 9, 2015 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) -r Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage'grinder is recommended B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying,septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old,is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 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. ElThe s tic tank and SAS and the SAS is less than 100 feet but 50 feet or system has a septic 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 pprm provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is Marstons Mills MA 02648 November 9 2015 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, ' provided that nd other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is Marstons Mills MA 02648 November 9, 2015 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z. ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site-inspected for signs of.break_out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is Marstons Mills MA 02648 November 9 2015 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use?. �.. , ® Yes ❑ No Water meter readings, if available last 2 ears usage 285 gpd 9 ( Y 9 (gpd)): Detail: 2014:95,000 gallons 2015:113,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: summer, 2015 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is Marstons Mills MA 02648 November 9, 2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cone.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is Marstons Mills MA 02648 November 9 2015 required for every , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 33+ years. Certificate of Compliance for a new system was issued 3/4/1982 (Permit#82-82 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): - Depth below grade: 1 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.): r Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank locate on site plan): ( p ) Depth below grade: 1 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: 10.5 x 5 x 6-1500 gallon Sludge depth: 3 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31 in - Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal - ❑ fiberglass - -❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: . . Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at 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.): No adverse conditions observed. F.. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments GSM 78 Sawmill Road -Assessor's Map 63 Parcel 65 - REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation,.or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leach pits. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9 2015 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.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 78 Sawmill Road-Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9, 2015 page. Cityrrown State Zip Code Date of Inspection Q. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately MYSTIC LAKE 11 OC /n S�§ONS THIS SKETCH IS L� /r—��1 0 11V BEST VIEWED IN —OF SEPTIC COMPONENTS COLOR FORMAT —DISTANCES IN DECIMAL FEET A B 1 20 25 . 2 26 32 3 22.5 29 LEACH LEACH PIT PIT 8 C3 DISTRIBUTION BOX �XQ�TING D�L LPL ING SEPT GALLON I 02- SEPTIC TANK 78 A Z � > NOT W TO 3 SCALE "r' 1995 \�y\ 508 364-0894 SAVw11 IVM§LL ROAD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's Name information is required for every Marstons Mills MA 02648 November 9 2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25+ 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: 3/1/1982 bate ❑ 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: Approved design plan on file with the Board of Health shows bottom of system is over 10 feet above the elevation of Mystic Lake. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y` 78 Sawmill Road -Assessor's Map 63 Parcel 65- REVISED TO SHOW 3 BEDROOMS Property Address Donna Friedman et als. Owner Owner's dame information is required for every Marstons Mills MA 02648 November 9 2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGIOL PROFILE "' — NOT TO SCALE ff LEACHING ' PIT BOTTOM OF ,+ LEACHING IS LEACHING w ABOVE HIGH � GROUNDWATER ELEVATION OF ADJACENT POND t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 1 f, SECTION - SEWAGE r SEPTIC TANK — — "D"BOX — — LEACH TOP OF RpN f=� (MSL)tk ,.2"OF IFaTO'h" ti{ NOTE: WASHED STONE 79 b ? REMOVE ANY UNSUITABLE MATERIAL FOR A DISTANCE ' OF 10 RT.AROUND ENTIRE LEACH AND REPLACE WITH CLEAN COARSE SAND. , + : �J /{ ! - d OUT- IN- OUT- OUT- p �staCa IN IN \,I� / !�/ r'� r SEPTIC GS,Q TANK ____ ELEV, _ ' `� U ! ELEV. ELEV. ELEV. I�.32 1t?.1I ' FF,.,. 4� , ELEV. ELEV. I : 'x' LL:'I I III 1 - / cr / "v ✓ { NOTE: Ir Z tj I { OF �W'- I41" .41 I t C, ( BRING ALL COVERS TO WITHIN - �{t d l I , i 1 FT.OF FINISH GRADE. �.ve WASHED STONE ' I ) / r/ / ,(p TEST HOLE LOG 44, h ILcala C� 2�ir i3.o.t ` J {l 7 f / TEST BY WITNESS _ ..� ♦� �~ �. i t ` C11 <\ \ f \ �- �2,3 TEST DATE /$( DESIGN __v__—BEDROOM HOUSE ' T.H. 1 �• T.H. # 2 V) tt/ +1 �� { 3 9.ca -I � 0-- ' Ce' cam- ELEV. ELEV. N /r DISPOSER UISPOSE'fi tt" a ff PERC RATE `' MIN/IN. __ 11r M _ t""*N d I { ( \ \ �., •. �� \\ \ j /; ✓ FLOW RATE 3 �c (GAL./DAY) atc.'1<I' SEPTIC TANK 3c) 0 )= _ � _ "' t REQ'D SEPTIC TANK SIZEr r, Co4i 4, 111 �G w n� .\ �- , St LEACH FACILITY III �f i <.w •, r^ �5c'_. c+. F'� >! - SIDE WALL t !L.(�7x`ta�' � .5: . i2 .5 ) �? _ G/t] t �` \ '�\ - '3<a BOTTOM (Ti'= 2w' - '( ,.cs } - � ' G/D, l 'u� j TOTAL dcs'_ s!� +�. �}2_S a 4, 1 (� s, _ ' __ E1.="jrj .. C.(.: —I USE; LEACHkNG t` :,r''e ae�, �Je:L 4 X f9� c 4'fr'Y i�yc: ..t„1r.MI_. WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) 1. DATUM(MSL)+TAKEN FROM SA�xC9v { __.QUADRANGLE MAP 2.MUNICIPAL WATER NCT _.__ .__,AVAILABLE 9.PIPE PITCH: IA"PER FOOT 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- 44 F S.MIN',GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. i i t ! h' . OISTAN > AS CERTIFIED, 6, PIPE JOINTS SHALL BE MADE WATER TIGHT i -A vl 11r SITE PLAN {7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. /' t i HEREBY 9'ERTIFY THAT THE $UILDING STATE ENVIRONMENTAL CODE TITLES 4 3(U C.-r.r Q. t5 �' ` �._ - , �- SHOWN ON THI$'PLAN IS LOCATED ON THE +.....tom�-�-GROUND AS SHOWN HE &THAT IT LOCUS: CONFORM TO THE ZONING BY LAWS OF THE Ai-I.570#415 TOWN OF 1, REG.PROFESSIONAL ENGINEER WHEN CSTRUCTED. DATE L SA*rtS i-!. �3pwM/;I : REF: fy4Q n Cape e4malfteel-late PREPARED FOR: r CIVIL ENGINEERS _ LAND SURVEYORS --- -------- i BOARD OF HEALTH REG.LAND SURVEYOR er �I CONTOURS (EXISTING)-•-•--------- APPROVED DATE SCALE _ (PROPOSED)—0-0-0-0— -- MA Yarmouth&Orleans,MA DATE