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HomeMy WebLinkAbout0115 SCHOOL STREET - Health 115 School Street,Marstons Mills l 1a a - { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street i LJ Property Address Maria Pietroniro Owner Owner's Name / information is Marstons Mill Y Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the�retum Company Name key. 374 Route 130 .. w Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Breµ H ..Digitally signed by Brett Hickey ll Hickey lcke y 'Date:2020.10.23 09:59:07-04'00' 1 0-22-2020 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street V� Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 '10-22-2020 required for every 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.: . I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass ,inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y . ❑ N ❑ ND (Explain below): i l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r , Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street u Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form w h' 1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street t Property Address I Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) Cesspool r❑ sspoo o 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 ❑ O 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ O Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ O Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ o Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ D 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc,rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 t t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every 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 El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? E ❑ Has the system received normal flows in the previous two week period? ❑ a 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) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ a 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ Q 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 Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /F 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1096/GPD Description: System permitted for 4 bedrooms per 4-10-1989 permit. Design flow taken from plans dated 3-23-1989. 1 ' Number of current residents: Does residence have a garbage grinder? ❑ Yes [j] No Does residence have a water treatment unit? ❑ Yes [j] No If yes, discharges to: Filtration system only (no discharge) Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes HI No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ® Yes (E No Water meter readings, if available (last 2 years usage(gpd)): See below Detail: ***WELL WATER*** Sump pump? ❑ Yes ■❑ No Last date of occupancy: CurrentDate t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 7,of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form - �= h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l� 115 School Street u� Property Address Maria Pietroniro Owner Owner's Name information is required for every Marstons Mill Ma 02648 10-22-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: NA 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- last pumped June 2018 Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 r Commonwealth of M• assachusetts �M Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: F. 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 n pP 9 P ( ) and source of Information: 1989 per permit and plans Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Distance from private water supply well or suction line: >100' from well to SASfeet Comments(on condition of joints, venting, evidence of leakage, etc.): l5insp.doc-rev.7/26/2018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9'of 18 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street V Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' .Depth below grade: 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 1 Dimensions: 500gallons 611 Sludge depth: 30" Distance from top of sludge to bottom of outlet tee or baffle 0if Scum thickness NS Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle NS measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v/ 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet 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: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity:p Y gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 L Commonwealth of Massachusetts w Title 5 Official Inspection Form I, Ito Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every 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.): .- - I "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. No evidence of past back up or leakage was observed. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is required for every Marstons Mill Ma 02648 10-22-2020 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.): NA * 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: (2) 6'x6' pit ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Of dal Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form = iIII Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 115 School Street u� Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every 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.): The SAS was in working order at the time of inspection. Both 6' leach pits had approximately 2' of ponding (1/3 full) when viewed with no evidence of past hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts �m Title 5 Official Inspection Form R ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street v Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA 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 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form �i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 115 School Street Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every 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 2y� .. see tc MAJts A A,P zsa ; Yy� p ,µp gyyyyy y�yyy� „„u+✓ _ ..w.rsadbman .. ... - y. �+_., ........ .K L3YXa&low 04 W#40'i DA,rU Pult TT tssumJi � Dil"I"FS: C.�.A2»?r,:�!i.1,,�k#517.':1ti-1,�-t� �..::.....� "'•�• `�� Uf­ '�� _ .. 'Nj° ✓�.mow I� i l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 ' Ili A ,( Commonwealth of Massachusetts ip Title 5 Official Inspection Form + Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street L� Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: 0 Check Slope ❑■ Surface water ❑■ Check cellar ❑■ Shallow wells NoGW@12' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked, date of design plan reviewed: 3-23-1989Date ❑ 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: A plan on file at the local Board of Health was used to determine high groundwater. Water is greater than 4' below bottom of SAS. 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 c Commonwealth of Massachusetts i Title 5 Official Inspection Form I?, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 School Street V� Property Address Maria Pietroniro Owner Owner's Name information is Marstons Mill Ma 02648 10-22-2020 required for every 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 0 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 Forth:Subsurface Sewage Disposal System•Page 18 of 18 /I-r TOWN OF BARNSTABLE V C - LOCATION ,ZO /Ll//_. � /,�,D6S'�- SEWAGE # VILLAGE ,�, '/isT /�C ASSESSOR'S MAP & LOT INSTALLER'S NAME 6i PHONE NO. SEPTIC TANK CAPACITY 'S-O D Y 7 LEACHING FACILITY:(type) .. /' � (size) �d NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ��-' 1� � y�-� � � � '� ���� � � � � � .� - , d �� No-a-9—... ... ­7 -ez-� ...... .. ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... F............V3 I....11.rr,r,.............. .15.A O.Le_ .......................................... Appliration for Bi-qVviial Workii Tonstrurtion Punfit 4 Application is hereby made for a Permit to Construct or Repair an Individual-Sewage Disposal System at: t .................................................................................................. ............................9#49nk....................................................... Location-Address or Lot No. ...................... >ate...AL..Ac'.�Kxliyj/.................................. ........................ Addres • . s & . *....7%r01hr4,,0T.T------------------ --------------------_-t�� ........ ONSM0 .......................... Installer staller Address Type of Building Size Lot___-U-j.A?-3......Sq. feet Dwelling—No. of Bedrooms.._.Ea�E.............................Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 Other fixtures ...................................................................................................................................................... Design Flow.....................................:5-5-.gallons per person per day. Total daily flow-------------------------_---540..gallons. WSeptic Tank—Liquid capacity./-��..gallons Length.��q..-19....... Width............. Diameter................ Depth................ Disposal Trench No..................... Width............._...... Total Length_................... Total leaching area--------------------sq. ft. 0.f...... I.......... Seepage Pit No._Mto--------- Diameter.......L - Depth below inlet...... Total leaching area....4F�.�__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......Alo rrwe2...6evPxm.aa............................ Date...._8/Z�/A 7.................. Test Pit No. 1......—-_-__minutes per inch Depth of Test Pit---JAft!...... Depth to ground water______________________ f14 Test Pit No. 2-----o2......-minutes per inch Depth of Test Pit....6zq........ Depth to ground wat ---- ---- P4 -TPd_j.;.Q-Z4'-I...L..6J......... 4" OF 0 Description of Soil...- ...5 m c-- tz ..0,n Z./1! _U1 0-ad..10AXn...L.. �4 ..5illoW.1-1- LWA1fh..._5dT?2W_ U7' .4.......................................... ---Ai-L-Y-N------- ------------- ---------------­------------................­................................................................................................. . ..... U Nature of Repairs or Alterations—Answer when applicable._---______________________________________ .............. No.30216 ;4- ------------ ----------------------------------------- ........................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in c the provisions of'TTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in 3.Z3 operation until a Certificate of Compliance has bee tied by the board of health. Signed........ ................................................................ ................................ Application Approved By..................... ........ ...............................- ................ ................ ......... Date Application Disapproved for,the following reasons:................................................................................................................ .............................................. ......................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... No... .._l..-/7/ Fps.. .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ow ............._OF............ T _t~... ApplirFation for Dhipmal Workii Tontitratrtinn Frrutit Application is hereby made for a Permit to Construct ( X ) or Repair ( ) an Individual Sewage Disposal System at: , I '---••-----...................................................................................... ............................ `' ........................................................ Location-Address or Lot No. f / �i.4.C!1:h-------------- ........................ `loaf...j ..........f Owner ////y����/� Address '/ ....-•----...--- -- -=• �.....S.S:.r.eaZ'r.... //���1��G9Ji /w/i/z%-_ / [. Instal UrAddress UType of Building Size Lot.... ......Sq. feet Dwelling—No. of Bedrooms.._.r v r.............................Expansion Attic (/I/,) Garbage Grinder �✓o) a`4 Other—T e of Buildin yp g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures . W Design Flow....................................;5�5..gallons per person per day. Total daily flow................................ `( --gallons. W Septic Tank—Liquid'capacityl:gOe?..gallons Length�o .�.- Width. ?&�__._ Diameter________________ Depth S --- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._-_J_(.-__)s---------- Diameter.......1.0._..__. Depth below inlet......6(.......... Total leaching area....4;E�.z..sq. ft. z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by....... ............................ Date..... .1 7 ,a -------------------- Test Pit No. I......"......minutes per inch Depth of Test Pit--- `t`....... Depth to ground water_._._._""____.....__. fsq Test Pit No. 2-----02.......minutes per inch Depth of Test Pit--- -........ Depth to ground water... ..�ctiD 1nau�; �tl+t, sub' tf ���}�� l4�1l lJ?�sr�tlitt?�. t -.......... . ��• D Description of Soil--- ----u-.)!Ok�j...ato��. U5U.? c...j....Z� —J ...._.'t17«(!.e1e!1..L.1hk:.✓c!yK sd.--r :1 Hn...Lft'- l ®� STEPHEN W X ALLYN v WIL'SON------ y U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------ A.�-� QA :- � .. -------------------------------------------------------•---•---------------------------.....------------•---------------------------------------------------------•••••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste the provisions of TTTF.,,.. 5 of the State Sanitary Code— The undersigned further agrees not to pla the system in��`���' operation until a Certificate of Compliance has been d by the board of health. 3.2J.pp Signed..;. ..... ---•-•. --'.................... -- D�t Application Approved BY o��------.--•- -- ""••'-""....-----•--••••.................. ---•-•..... - Date Application Disapproved for the following reasons-----------------------•----------------------------------------------------------------•-. -••-•-•.........-" ..-----•--•----------------------•----•---.........-----------•--•---------•-----•-------------------....._...-----------•-•----------------------------------------------------------------------....._. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............a�...............OF.......... f1 �2ry YcC ....................... CInfifiratr ,af fauntpliatta THIS I - TO CERTIFY' hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) I �11 by......................................................... ..-.. -....__5 ?.:=. _.� Installer f a_.. v (^ j y ................:- �' =_.5-► s J_..`-.---- ,------�1/�_(_ ` at , .................................................•......... has been installed in accordance with the provisions of TITIZ 5,of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... .......L-7_.l..... dated..........'._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................................................""--•--...-"--'-''.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS �.. BOARD OF HEALTH -Z�5 cl 7/ ./....Jw .s- F NO......................... EE.....-..-�:........... Disposal Workii �n rnnr irrn prntt# Permission is hereby granted........ !- T to Construct ),Tr Re,Pair4 ) an Individual Sev&a e Diispos System at Street i f as shown on the application for Disposal Works Construction Permit No. ..... Dated.._..�� •- -r; L� Board of Health DATE.............. - D FORM 1255 HOBBS & WARREN. INC., PUBLISHERS v� 10/22/2020 ShowAsbuilt(1700x2800) I/s TOWN OF BARNSTABLE 1-145 LOCATION�Q� fhla�c�S% SEWAGE# VILLAGE ASSESSOR'S MAP Q LOT INSTALLER'S NAME&PHONE NO.�j��d�t �C�'1T1�712-3/fir SEPTIC TANK CAPACITY LEACHING PACILITY:(tV e) � � (size) `NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERL�f� s DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: le'.. VARIANCE GRANTED: Yes No 1 https:HitsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuiIt?mp=046013003&sq=1 1l1 No. -----1 Fee-�A� BOARD OF HEALTH TOWN OF BARNSTABLE AppricationArVell Con5tructionpermit Lon its�h�ereby made or a permit to/ypCgastruct ( Alter ( ), or Repair ( )an individual Well at: Location Add es Assessors Map and Parcel a- --------------- ----------------------------------------------------------------------—----------------- D Owner Address - �� - --------------------------------------- - - - Inttaller — Dri Il er Address Type of Building Dwelling--------------------------------------------------------- Other - Type of BuildingNo. of Persons-------- -------------------------------------_____ 4 - -- Type of Well---- �� ------------------------------------- 1 YP -------- -- -� --------------'---- Capacity---------------------------------- Pu Purpose of Well---- > �---______ __ _ ____rp E , Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificat of Compliance has been issued by the Board of Health. Signed date Application Approved By---- - __ _ ___—__________ date Application Disapproved for the following reasons:-----------------_______—____—-----_---------------____:______—---------------___ t ---- - - - - - — --- - --- —- ------------ w N date PermitNo��` -------- -------------- ------ Issued--------- -t ------------ ---------------------- date x , BOARD OF HEALTH TOWN ,."OF ,. BARNSTABLE Certificate Of Compliance Is THIS I O CE Y, That e di i 1 o s ructedXAltered ( ), or Repaired ( ) by--- 1 - � - ---- ---------------------------------------------------------------------------------------- ]er A_AV �C�-------------------------------------------- has been installed in accordance with the provisions of th Town of Barnstable Board of livalth Private Well rotect' Regulation as described in the application for Well Construction Permit No. Dated- -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS-A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. �r DATE---------=------------------------------------------------------------- Inspector------------------------------------------------------------------- Y No. Fee-- --a-------------- { BOARD OF HEALTH TOWN OF BARNSTABLE 2(ppYication-*rVell Con5truct ion Permit Appliatio��is hereby made for a,permit to Construct ( gyp)/Alter ( ), or Repair ( )an individual Well at: r - 1 .- — T A _1 . . �� ------------------------------ Lo ation — Add s� Assessors Map and Parcel /M/ Owner F Address -a"y:-.I `-------- > `--_"-I�- '---j' ----- + ------------------------------------------------------------------------------- Installer — Driller Address Type of Building Dwelling t Other - Type of Building- ` No. of Persons------- - -- -=---------------------- Type of Well- - l `7 � ---------------r Capacity — --- Purpose of Well----- - - -(-- Agreement: l; The undersigned agrees to-installlthe aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health,Private Wellf Protection Regulation'w=';The undersigned further agrees not to place the well an operation until a 'Certifit:ate-of Compliance has been isiued-by the Board"of Health. Signed !/!= % G _/✓r?',e�,.,rl�r_� 1� —Jo�F--'_-9 date Application A roved B.=- - —�A !�� - ---�-'- PP PP Y 1�� — — _ date ------- rov ed By- :,�Jlow f Application Disappro fed for the fJfollowing reasons:------------ — —_ ___ — tt date Permit No.'- � ='! --- -- _-=-- Issued----------- ���----- —-- _-_ a date t y �BOARDgOF.HEALTH �- lei TOWN �OF BkRNSTABLE Certificate Of Compliance �Y THIS IS TO CERTIFY, That the I dividual = 41 1 ,onst ucted'(Altered ( ), or Repaired ( ) nstaler has,been installed in accordance with the provisions of the`Town of Barnstable Board of Health Private Well Brotecti�n Regulation as described in the application for Well Construction Permit-No. - / ) �'_/_ Dated�7�— a r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. n DATE-------------------------------------- -------------------------- Inspector BOARD OF HEALTH H TOWN OF BARNSTABLE Melt Co0truct ion Permit No. ------------r""" Fee-- - ------------- c I���✓ b�l jrf Permission is hereby granted---.� --------� ----eL�-------- to Construct ( )�Alter ( or Repair((/J� ) an Individual Well t/j No. "- Stre[ as shown on t .e application fo a Well Construction Permit V No.- _//1 - - ..--.__� --------------------------------------- Dated -� -4 ," T — —— —_—--`, — Board PfAlth DATE - - - - - -------- ¥_r . . q .. ^ ENVIROTECH LABORATORIES § k . % 49 Route 13 Sandwich, MA053 - (50) 8y66 q k � � ® k CLIENT: Steve Kenney LOCATION: Same ADDRESS: Lot 2 School St. q _E Ha£Sto s Mtlls, MA 02648 k % COLLECTED BY: to f7 SAMPLE DATE- 10/12/8989 T mE 10:30RAM DATE RECEIVED: SAMPLE ID: q f New Well ® � JOB WELL DEPTH: � K RESULTS OF ANALYSIS: d � k BE.:: Parameter Units Recommended limit Result q k � Co br b der/10 ml (F Method) O # pH pH pb 6.Oa3 k Conductance umhm/cm 500 � k w Sodium , mg L 20.0 NU2eN mgE I&O % °on mg/L 0.3 � k : Manganese mg/L 0.0 e K Hardness . . mg L as CaCO a 500 F = Sulfate mg/E 250 � Potassium mg/L 20.0 � k Q Alkalinity mgL 00 � � 2 k Chloride mg/L 250 F q # � EE Turbidity NTU . &O 66a APC units l&O q 3 Background bacteria A � 2 & COMMENT . _E / 00 EPA Method 502.2 G9/t Bee attached r port 3.0 Chloroform Chloroform is occasionally found in to concentrations in groundwater 2e . kYES No VAM&IMfA2EPPS0'R' bRNWG%0-3\i'FOR PARAMETERS TESTED. k E.- d A A DATE 9 a _ . . 2 7 ;. .. . GROUNDWATER ANALYTICAL EPA METHOD 502.2 Volatile Organics (GC/PID/ELCD) Sample Designation: #437A Project Name/Number: Envirotech Laboratory Number: 928514 Date Analyzed: 10-16-89 Sample Matrix: Water PARAMETER CONCENTRATION DETECTION LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BDL 2. 0 Chloromethane BDL 0.5 Vinyl Chloride BDL 0.5 Bromomethane BDL 2 . 0 Chloroethane BDL 0.5 Trichlorofluoromethane BDL 0. 5 1, 1-Dichloroethene BDL 0.5 Methylene Chloride BDL 0.5 trans-1, 2-Dichloroethene BDL 0. 5 1, 1-Dichloroethane BDL 0.5 2 ,2-Dichloropropane BDL 0.5 cis-1, 2-Dichloroethene BDL 0.5 Chloroform 3 0. 5 Bromochloromethane BDL 0.5 1, 1, 1-Trichloroethane BDL 0. 5 1, 1-Dichloropropene BDL 0. 5 Carbon Tetrachloride BDL 0. 5 Benzene BDL 0.5 1, 2-Dichloroethane BDL 0. 5 Trichloroethene BDL 0.5 1, 2-Dichloropropane BDL 0. 5 Bromodichloromethane BDL 0. 5 Dibromomethane BDL 2 . 0 Toluene BDL 0.5 1, 1,2-Trichloroethane BDL 0.5 Tetrachloroethene BDL 0. 5 1,3-Dichloropropane BDL 0.5 Dibromochloromethane BDL 0.5 1,2-Dibromoethane BDL 0. 5 Chlorobenzene BDL 0. 5 Ethylbenzene BDL 0.5 1, 1, 1, 2-Tetrachloroethane BDL 0. 5 m+p Xylene BDL 0.5 o-Xylene BDL 0.5 Styrene BDL 0.5 . Isopropyl benzene BDL 0.5 Bromoform BDL 2. 0 1, 1, 2, 2-Tetrachloroethane BDL 0. 5 1, 2, 3-T.richloropropane BDL 0.5 Page 1 of 2 r GROUNDWATER ANALYTICAL Sample Designation: #437A 928514 PARAMETER CONCENTRATION DETECTION LIMIT (ug/L) (ug/L) n-Propylbenzene BDL 0. 5 1, 3 , 5-Trimethylbenzene BDL 0.5 2-Chlorotoluene BDL 0.5 4-Chlorotoluene BDL 0.5 tert-Butylbenzene BDL 0.5 1, 2, 4-Trimethylbenzene BDL 0.5 sec-Butylbenzene BDL 0.5 p-Isopropyltoluene BDL 0.5 1, 3-Dichlorobenzene BDL 0.5 1,4-Dichlorobenzene BDL 0. 5 n-Butylbenzene BDL 0.5 1, 2-Dichlorobenzene BDL 0.5 1, 2-Dibromo-3-Chloropropane BDL 3 . 0 1, 2 ,4-Trichlorobenzene BDL 0.5 Hexachlorobutadiene BDL 0. 5 Naphthalene BDL 0. 5 1, 2, 3-Trichlorobenzene BDL 0. 5 BDL = Below Detection Limit. "Trace" indicates probable presence below listed detection limit. Method Reference: Method 502.2 - Volatile Organic Compounds in Water by Purge and Trap Capillary Column Gas Chromatography with Photoionization and Electrolytic Conductivity Detectors in Series, U.S. Environmental Protection Agency, Environmental Monitoring and Support Laboratory - Cincinnati OH, September 1986. Page 2 of 2 ttiiitiitflitiSittitifiit?111itittiiifSStiittittitt(ttltifiittttitiftSf�itiiiiftSf tititfitftfiiifiifiiitf(itiitiStliiSitif tiliitf tlittftiillltitittititiitiliitlltifitftfifiifSi111TSTttitilitiftltiiiititittiiiitiSiitiiititiiiiiitiiiiftiittil/iJ ENVIROTECH LABORATORIES _ 449 Route 130 Sandwich, MA 02563 • (508) 888-6460 it CLIENT: Steve Kenney LOCATION: Lot #1 School Street' - ADDRESS: Marstons Mills.MA COLLECTED BY: T. Leary SAMPLE DATE: 9/5/89 TIME: 12:00 N = DATE RECEIVED:9 5 89 SAMPLE.ID: M457 JOB #: New Well WELL DEPTH: 72 ft RESULTS OF ANALYSIS: _ Parameter Units Recommended limit Result —' .= Coliform bacteria/100 ml (MF Method) 0 0 _ PH pH units 6.0-8.5 5.60 iw. Conductance umhos/cm 500 74 - Sodium mg/L 20.0 7.9 - r Nitrate-N mg/L 10.0 .82 Iron mg/L 0.3 <.05 Manganese mg/L 0.05 ; .= Hardness mg/L as CaCO 3 500 — Sulfate mg/L 250 Potassium mg/L 20.0 — Alkalinity mg/L 200 Chloride rng/L 250 =- _ Turbidity NTU 5.0 j Color APC units 15.0 Background bacteria COMMENT: � J YES No, WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS T TEDZDATE R xxX -p-- �1„ltiibltllil,i!!11!!!U!!1►!!!,!!i!!!!!!!1!!,i!!!1l+111l11i,!!!!l111+,1,11i„!!!ll,isiti,lli,l,,,l►ll,t,Illi,llulillllUl!„!1L!ll,1,U,11,!!„+1i,liLlliWWII# ,1!!i+„!„!li11111,►„l11ifl,Illl!!!!+!1!!!!l1111U1ii,!!!llilf!l111�` 'S �y e�� / 7-f r.' 1 f� {ct' V J- 1f I I P i l �� �tllf'ii;ifii!Stfit1tf111111'illi{#t11i11111I=tttiililiiit'iT!iitiTTiTtt'ti[ii!ifi1TTFtiiiTliiitit[fltlTi1nT11Fif!1T1TttFntttlPTT'Fiif!itiiii!tiii't111111FiF'tliii'li[i((iiijiiit!'ttnTTt111111.tif►i'iit1111iiiiitiTflTfj, ENVIROTECH LABORATORIES 449 Route 130 Sandwich, MA 02563 • (508) 888-6460 E-' -CLIENT: Steve Kenney LOCATION: Lot #1 School Street ADDRESS: Marstons Mil1s.MA ,rOLLECTED BY: T. Leary SAMPLE DATE: 9/5/89 TIME: 12:00 N - _ DATE RECEIVED:9 5 89 SAMPLE ID: M457 New Well 72 ft JOB #: WELL DEPTH: RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 5.60 c: Conductance umhos/cm 500 74 Sodium mg/L 20.0 7.9 Nitrate-N mg/L 16.0 .82 SF iron mg/L 0.3 <.05 Manganese mg/L 0.05 Hardness mg/L as CaCO 500 3 Sulfate mg/L 250 Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride rng/L 250 Turbidity NTU 5.0 Color APC units 15.0 BE. Background bacteria COMMENT: EF YES No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS T TED. xxX '❑ DATE 3 l lllsii: t11111j!!j}jjjj!!1llllltltIW''illf WiWll!>!1#111t1illilElli!!i!!!!lltlillilttulltlUil lti!llilitiUillll#tlullilitilllfil liUliliulilttlt!!i! tttttltililiilltl!!!t!!!lltllUlt!!lltllllWlll!!tllllil�lllA miasmal �aW®rrr r� ■r■�°� Mimmmiiilo ■ � on rr►Ir■ gasr■s■■'� YA ®err ■c�v_; , _ -S�;'�� iii _m.■i■, �mmia:� am on San logs, NQa " ° o ° ��■■� ■■ a ■r°■° ■P11 ■� iMIR rV.0zz n■r�■■■�iiii ��� rr■■. ■ ■tNo t■■■ �NVO ® r�i'iu■■r■u■■ IV a run WIN ■■i ■ now 0 s � i _ SN_ Commonwealth of Massachusetts Executive Office of Enviromiental Affairs Dept. of Environmental Protection One winter Street Boston,Ma. 02108 .title Septic D.B.P. Title V Septic Inspector kip P.O. Box2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION SEC t 5 jc9T Property Address: 115 School St.Marstons Mills Address of Owner: Date of Inspection: 1214197 (If different) Name of Inspector: John Graci Country Wide Home Loans I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined In Title V _ Conditional) Pa Se5 code 310 CMR 16.303.My findings are of how the system is performing atthe time of the Inspection.My Inspection does _ Needs Fur er valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Falls septic system and any of its components useful life. Inspector's Signature: Date: 1214197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The systern, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised(MIM197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 school SL Marstons Mills Owner: Country Wide Home Loans Date of Inspection:1214197 _ Sew.aae backup or,breakout.or hiah.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. _ SAS is in hydraulic failure. (revleed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 School St.Marstons Mills Owner: Country Wide Home Loans Date of Inspection:1214197 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No",as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within.400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (rerlaed 04@A97I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 775 School St.Marstons Mills Owner: Country Wide Home Loans Date of Inspectlon:1214197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following. _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x _ The facility or dwelling was inspected for signs of'sewage back-up. x _ The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.Q.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (reyleed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 115 School St.Marstons Mills Owner: Country Wide Home Loans Date of Inspectlon:1214197 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 448 g'p' Number of bedrooms: 4 Number of current residents: 0 Garbage grinder(yes or no): Yea Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No last two 2 year usage d Water meter readings,if avaiIable:(as ( )y g (gp )' rda Sump Pump(yes or no): No Last date of occupancy: one year ago. COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow.o gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nla Last date of occupancy: nla OTHER:(Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)Ho If yes,volume pumped:-0 gallons Reason for pumping: va TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no)_( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source information: 8 years Sewage odors detected when arriving at the site: (yes or no) No (revlaed 0427W) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 School St.Marstons Mills Count Wide Home Loans Owner: Country Date of Inspection:1214197 SEPTIC TANK: x (locate on site plan) Depth below grade: 16" Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L10'1"11s7'wb's^ Sludge depth:6" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness:7" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 12" How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system now and then malntalned every year. GREASE TRAP: (locate on site plan) Depth below grade: da Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rva Scum thickness:rva Distance from top of scum to top of outlet tee or baffle:nta Distance from bottom of scum to bottom of outlet tee or baffle: We Date of last pumpingn- Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 2- Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction fine?own Diameter: 4" greimments: (conditions of joints,venting,evidence of leakage, etc.) (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property art Address: tts school St.M arstons Mills Owner: Country Wide Home Loans Date of Inspection:1214197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_Polyethylene—Other(explain) Dimensions: nra Capacity: Na gallons Design flow: Na gallons/day Alarm level:_nla Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nia Comments: (note if level and distribution is equal, evidence>>f solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Na (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 School St.Marstons Mills Owner: Country Wide Home Loans Date of Inspection:1214197 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: roa Type: leaching pits,number: f,oW gallon leach pit leaching chambers,number:nla leaching galleries,number: nla leaching trenches,number,length: roa leaching fields,number, dimensions:nla overflow cesspool,number:roa Alternate system: roa Name of Technology:_roa Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leech pit was empty at the time of the Inspection.it show signs of being full,system was not Inspected uder normal use,because property has been vacant for a year. CESSPOOLS:_ (locate on site plan) Number and configuration: roa Depth-top of liquid to inlet invert: roa Depth of solids layer: roa Depth of scum layer: roa Dimensions of cesspool: roa Materials of construction: roa Indication of groundwater: roa inflow(cesspool must be pumped as part of inspection) rig Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) roa PRIVY: (locate on site plan) Materials of construction: roa Dimensions: roa Depth of solids: nta Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rds (revised 04)27)971 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 115 School St.Marstons Mills Country Wide Home Loans 12J4197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I Gtx��C OC AA AC 30 t� �C 3� (revlaed04)27197) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 115 School St.Marstons Mills Country Wide Home Loans 1214197 Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health s Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (rwm.d o4m��1 page 10 of 10 { I.71 IA. t <7 7 -_ - z ,^ SI,lo23 5P — V I q- - TK 1- - __--••-- ,-� PiT Ib�Olin F. 1 , / IF ENCOUNTERED/ ALL UNSUITABLE SOIL - - } 1 {ALA•► YIIr� SHALL BE REMOVED WITHIN A 10' WIDE -- " ZONE AROUND THE LEACHING FACILITY i I • AND SHALL BE REPLACED WITH CLEAN 1 A�lowwb � Flow SAND AND GRAVEL IN ACCORDANCE WITH B Fitt c 7c@ K ( c:c`+c ( TITLE V. J� i � f TEST HOLE 1 rcih - � in-, P- rc�r.A G I(l1I, ic,i'J tc 4" SC, 40 EL_ Inu•L 1NV wv 7 v C 8 GAL (+(J -- (� ^I Lr DI$T - h SEPTIC ' . . Box �i•z. qJ Ic � r y � TANK . - f_ p walr� T+ t . I i t���i L` _g¢ L v✓r-4 I` DEVELOPED PROFILE ALONG ' ' l ..PROPIOSED_SEPTIC SYSTEM �- 577 - NO SCALE I : : ( . = ��'� ' 1� COSIGN-DATA P -^—r---. , [) g�� STEPH LN - SINGLE FAMILY-A. BEDROOM � 1 y,.. .i�t'� n;r cJ WILSON I Np: . DISPOSAL l z y r� i �0o 24049 � No.30216�� 1 GN FLOW=4-x 110 ^44v GPD. f T K- USEI�GAL . OSAL 5 'Z? ►066i-A /s'5 ---' .i �,� PLOT PLAN OF LAND ( IN I `iI? � SIDEWAL ( � i .� j L. AREA= '3 !0 5F; , BOTTOMxAREA= q� 0.? . . L:. " C f= `tit T"t%tv;> , ;+( .4; /VI A _l x --TOTAL'DtSIGN ioleo-GP FOR f , ,TO.TAL:FL!OW =. :4dv:4-�'t� o�. C�1'rr`i�ri� � t<✓1 ��.;t� � f �P COLATlON RATE i IN 2 MIN OR LESS SCALE: I"= BR DATE: 3�23 -I i BAXTER 6 NYE, INC. T REGISTERED LAND SURVEYORS 10E1RTIFY THAT THEtiW"..ra& SHOWN HEREON $ :COMPLYS WITH THE SIDELINE'AND SETBACK CIVIL ENGINEERS ' ='REQUI MENTS OF THE TOWN OF 13A�nI�T43c. OSTERVILLE, MASS. -j , t T. _ }iS ; LOCATED WITHIN THE!1700D PLAIN; .17 41 REGISTERED LAND 'SURVEYOR f' �' I- r' ' 89'L13 J t I _. IY 4F _ r _ - ....._._. d., 1 . 1:: I T_-Ttr ' t 111 I 1. ji. , '. , _" —t--___;-_---h_ i�` - - - ._�.. .. ..... .. ... .. .. _ - y : -..__ - -. _. _. S t t o r c sysMJ, , .. _ - , i i ' i } I WITS{1u Renr_-, I „-t, �. i ' �,. _ Pwo ;1i�ELL Ste'' ,` t .. :-. . }. Ii. f; ; . - z .1 t. � , _ _ t I f t i , -4 ' �` O : } _. - 1 ; I R I - .1 Piz�:; . j - 7 i r fi —� o 1 ado•81 ? , _ 7 i- , :� , �45'p' . , t_'i r 1 ; I I �: I � �� ~�.,. N _ .., -— 9 r i , rt _ _ L 0� (. t T I ,_....,. t q PJzat� _... i 8+,'le23 sal f 1 ,w 1 ► , _ 1. f _ I Zo oI `3,,. S.A , ,f + _ , -t ,.. - /�/ MIN f 'I: 7 L.. -�.. .. .. 1 P� ill TK :I Rom. -1 101 I_rA�a _ _ z.�'. :. ;- : , i r ra �' • } ], ': _ fit , 1 - d o _. .,-.. _._ vmn :, 3w 1 _i -_ r 4,:_ Io1.2. I _� i T_ i i I - - ,� T .r._..-. .. - _ ry.�t,R of -. 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