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HomeMy WebLinkAbout0136 STARLIGHT DRIVE - Health 136 STARLIGHT +� v A= 099 049 ;7,r ti qq C� µ c Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form � Irr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T_' r.1 136 Starlight Drive z.'r u, Property Address Stephen Whalen Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-28-19 page. City/Town State Zip Code Date of Inspection r , 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 �y� .A. Inspector Information z5/# c � on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 �a Company Address Sandwich Ma 02563 City/Town State Zip Code r (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 c' ol 8-28-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive V Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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," lease explain. , P P 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 ifiit is structurally-sound, not eaking and if a Certificate of Compliance indicating that the tank is less Than 20-years old is available.. ❑ Y ❑ N ❑ ND (Explain below) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 4 c Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 136 Starlight Drive L Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 t c°f'\ Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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 ❑ El 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 '/day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 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 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form + Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 136 Starlight Drive Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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 0 ❑ 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? El ❑ Has the system received normal flows in the previous two week period? ❑ Q Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ [E] 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. ❑ 0 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive v Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 539/GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes [j] No Does residence have a water treatment unit? ❑ Yes R] No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 91 No information in this report.) Laundry system inspected? ❑ Yes EI No Seasonaluse? ❑ Yes Q No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2018-45,000gallons 2017- 50,000gallons 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 �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive u= Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 9 months ago 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form lol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive v Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 4-23-86 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 L <14 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1'6" 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 1000gallons Dimensions: 1" Sludge depth: 35to Distance from top of sludge to bottom of outlet tee or baffle On Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle 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 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive V Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day . t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts �n ,ip Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 136 Starlight Drive Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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.): *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. t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 official Inspection Form f' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive Lv� Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every 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: Elleaching pits number: (1) 6'x4' 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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. Pit was 1/2 full when viewed. 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 3./ c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive u Property Address Stephen Whalen Owner Owners Name information is Marstons Mills Ma 02648 8-28-19 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 Commonwealth of Massachusetts J �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; 136 Starlight Drive v� Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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 faC"l4II®t�l d s's? r %r c SEWAArM,x vn Cls;� c�r assr C WS MAP SEPMC TAXK L J3I'ACITY F LF.ACIM1143 NO 91113 tcx».fy11s st�ILcER Uj! t�W�rirta �f`t r ra REI21Sti1T Dq Tom:'- COMM' ANCr l7A I Iw paa°xxicara-his"�Het�vean cfae: Mixasaiaen Adjus-ted Gr«undWater Table,and Hoftem of Leaf- iWA;.F_X ity. Feet Private Waiter Sirpply WeH'aor3 Lea Chir4.F'acii ty. (It any,welts t)usi an site or viiitaia ©t3 t` f lauc ung fac ty Foet ci s erY!WclXattti aad I aeacl ritsg I+uc iity(Xf nny weds enstt wittua- llC1'foer.oi.ieeaiirig,feecciiy 1 4w�et Furnished by" _ t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 . 3 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: X Check Slope X Surface water ❑■ Check cellar ❑■ Shallow wells Estimated depth to high ground water: NoGW@10'feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record 10-3-1985 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 a c Commonwealth of Massachusetts Title 5 Official Inspection Form11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Starlight Drive v� Property Address Stephen Whalen Owner Owner's Name information is Marstons Mills Ma 02648 8-28-19 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. ❑ s ecto 0 p p ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ■❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection:- Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M �< 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 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 A. General Information forms on the computer,use 1. Inspector: -- only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 5Q8420-4534 S14297 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 ❑ Needs Further Evaluation by the Local Approving Authority 12-19-13 Inspe 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;doew: ot;address,how the system will perform in the future under the same or different conditions,-0 use. t5ins•3113 Title 5 Official Ins e 1i Form:Subsurface ewage Di posal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MET MINIMUM PASSING REQUIREMENTS AT TIME OF INSPECTION, CAN NOT PREDICT FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE, THE SYSTEM APPEARS TO BE ORIGINAL. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection, Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. City/Town 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. r 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection-, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 136 STARLIGHT DRIVE Property Address LEGER Owner Owners Name information is required for MARSTONS MILLS MA 02648 12-19-13 ' every 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 laborato y jor.._fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is'equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 Y2 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 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is.required for MARSTONS MILLS MA 02648 12-19-13 every page. Citylrown 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 lesshtban 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 11 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 I Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is MARSTONS MILLS MA 02648 12-19-13 required for _ every 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 for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, ,depth of liquid, depth of sludge and depth of scum? P q P 9 P ❑ ®. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND LEACH PIT,SYSTEM IS NOT DESIGNED FOR GARBAGE GRINDER Number of current residents: 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 d SEE BELOW 9 ( y 9 (gP ))� Detail 2012------238 GPD 2013-----137GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: 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.): 4 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 Forth:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not,for Voluntary Assessments 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. Cityfrown 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: 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 1/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 Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 136 STARLIGHT DRIVE Property Address LEGER Owner ion is Owner's Name informrequired for MARSTONS MILLS MA 02648 12-19-13 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: SYSTEM APPEARS TO BE ORIGINAL Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 1.5 + feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yeah Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: MODERATE t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is MARSTONS MILLS MA 02648 12-19-13 required for every page. Citylrown 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 Scum thickness LIGHT IN SMALL CLUMPS Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YRS 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 Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 136 STARLIGHT DRIVE Property Address LEGER Owner Owners Name information is required for MARSTONS MILLS MA 02648 12-19-13 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 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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 Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 'y< 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): PIT WAS OPENED AND HAD 3 FT OF LIQUID AT TIME OF INSPECTION. THE STAIN LINE WAS AT ABOUT 15 INCHES FROM THE BOTTOM OF THE INLET PIPE THE BOTTOM OF THE COVER AND INSIDE OF THE PIT SHOWED NO SIGNS OF BACK UP OR HYDRAULIC OVERLOAD 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 Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. City(rown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is MARSTONS MILLS MA 02648 12-19-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. Cityrrown 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: GREATER THAN 5 FT feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: AUGERED IN LOWEST PART OF THE BACK YARD TO 5 FT BELOW BOTTOM OF PIT NO G.W ENCOUNTERED 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 136 STARLIGHT DRIVE Property Address LEGER Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-19-13 every page. CityrFown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE t/ LCCATION Q! J 1-0 12V 3r/LU t: SEWAGE # VILLAGE aLS40M 1Z i1S AS: R'S MAP &LOT 9g �5�1�• ivSPGes � /U ,'/ / c NAME&PHONE NO I rJIL �7 E/ 6? SEPTIC TANK CAPACITY 1006 a/ �, c t/ LEACHING FACILITY: (type) (size) C/O� NO.OF BEDROO 3 BUILDER OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �T kts t- 33, 5a � 3�' o Cep F /3 LOCATION SEW -AGE PERMIT NO. VILLAGE l90 I.XSTA LLER'S NAME L ADDRESS . E U 0 L D E R OR OWNER DATE PERMIT ISSUED VATS C 0 M P L I A N C E I S S U E 0 7�c 1sG r Lo 66 ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 ,,?A R.W.&N.13 L-7e.................................... Appliratiou for Bisposal Nfarks Tow5trurtion "amit V Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ....bp..................... ......................... -----K..................... ------------------------------------------- Location 7 Locn-Address or Lot o. ............... ..... .(),I.Lb. ................................ ---------- - Owner Address . ::j.. - rr .. ... ...................... .......................7 .. . ...../4�1. ...... Installer Address Type of Building Size Lot----- ----Sq. feet Dwelling—No. of Bedrooms..........3............................Expansion Attic Garbage Grinder PL4 Other—Type of Building ............................ No. of persons.....................___._.. Showers Cafeteria 0.4 Other fixtures -----------------------------------------------------------------------------------------------------------------------------------�L................ Design Flow......9.1 ...........................gallons per person per day. Total daily flow........?3.o..........................gallons. 1:4 Septic Tank—Liquid capacity......I....gallons Length...49......... Width_,_____--- Diameter________________ Depth..,S--v'"'"-' Disposal Trench—No. .................... Width.._......._.._._._.. Total Length.................... Total leaching area-----------_------sq. f t. Seepage Pit No--------------------- Diameter.._..........._..... Depth below inlet.._................. Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing�_ Percolation Test Results Performed by______________ ---------_----------- Date_._,?:-._.n�45................. Test Pit No. I....... ..minutes per inch Depth of Test Pit.................... Depth to ground water.....A_.1.1-------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit....._._........._.. Depth to ground water----___--_____--._._.-. a ...................................................................................................................................................."--------- 0 Description of Soil.................. ....Alm.rm............41...... -------- W U .....LA, , /k --------------------------------------------------------------------------------------------------------------------------------------------------------- ... ....U/ _ACIMA' ................ --------- .............................................................................................................................................................................. 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'L I TL!L- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until'a Certificate of Compliance has been issued by the board of health. .. . .................. Date Application Approved By. .... ........................................ .................. Date Application Disapproved for the following reasons:......................................................................... ......................... .................. ..................................................................................................................................... ............................................... Date PermitNo.......................................................... Issued....................................................... Date Fims............................. ITHE-COMMONWEALTH OF MASSACHUSETTS a _ BOARD OF HEALTH i{ rwvvp................OF.....�!;?.fa .t - � - -.............. ApplirFation for Disposal Works Toustrnrtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. •.............. +�! .r .. ors t ...........---•-•----••-••---•. __ 5'r9•t" 1v.�I.. '..1`'•° ! ?r(s5 . Owner c / Addyrress Installer Address Q Type of Building Size Lot......`' <." ...Sq. feet V Dwelling—No. of Bedrooms........... ............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers W YP g -•------•------------------- p ( ) — Cafeteria ( ) QOther fixtures .---.....-•-•----•------•----------•---•-----•--•-•-•.•....•••....................................................................................... Desi Flow--'-'--• •-I-�- •----------------- ,S'30 W gn ` gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity....... ...gallons Length----.R........ Width._:__-___- Diameter_______________ Depth.., x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing..tank,,( `" Percolation Test Results Performed b "' r, C'a � !2 Y ----•-...... Date -•-•-••'-"•----•••--- Test Pit No. I..._.._: ^n minutes per inch Depth of Test Pit.................... Depth to ground water......{ .../------__- fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._......_........._____ PCi .....-•-•--•-••.................•-'--••--••---•..........--•-•---•-••........................_..............._-- O Description of Soil...................." , ................................., ._ r� �? �'2A ar'��= �ta ,nT e 0 �+;rI`� .S•mot,. ..................•.............•--._........_..................--._...---........ U 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_TII lE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been�issued by the board of health. _ Signed ' IU f Date Application Approved By.....-- •-- .................................... •..=----11 Date Application Disapproved for the following reasons:.............................................................................=�...........•-•--•............ - •'-••........•••---••---.....•----_......•---•----'--------•••---------•.....••••-•'.......••••----•••••------•---•-----•------------------------•------------------------------------------------'--••. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF.......... �?5� ............ C9rdifirFate of TumpliFanrr THIS IS TO CERTIFX4hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by -�... .._c....._......._.............-----------------------•-••-----'-••-•----------..............----•--•---'----•-------........----------'------ / c In st Ller at. �.. 1.- r..1. .t_a.__.._.:_ f.iu ---•...............................•-•------- has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code/as described in the application for Disposal Works Construction Permit No.-__--_-- ,Y,_-._j.�l._.. dated_--.___-_._- ?.! '� .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT,EE CONSTRUED AS A GUARTEE THAT THE SYSTEM WILL FU� IONS TISFACTORY. � DATE.......................... ff�� ................ Inspector.................................................................................... Sr F Y t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j No..C-`• .R...+ FEE M. r a............ Disposal Works Tn �*nrtim_rn prrmft Permission is hereby granted _�;: :�. -' —= ,` ------•-•-------•-•-••-•--•---••-•-----•--•-•_•.........................•...........•-- to Construct ( 0-.or--Repair 14n individual Sewage Disposal System at No...............j•-^•1 f. .�rr...--•-• _4, t_ !, .._.. y Street as shown on the application for Disposal Works Construction Permit No ._.�?' Dated.......... Al --------•------ Board of Health 7/1 �.> DATE........... '=� . -�}-y--0-�-�.C-=------------=- FORM 1255 H1OBBS & WARREN, INC.. PUBLISHERS ' -�07' iYSy 7f�$�S3 Q1 �- o�Sr! -a1SiY//Yq-iv p O�Siyfr 1o/V s•/ /Yy 770�f7rY,t -"� 7�',7 f" ` $_l�,-101 '21 l - j�!y •� �-/�i�a.�s� �o/Y S/ Qivly ��yr}���r��v �ixo1 S�'oi(�'ita•/7S'oNY?Q-��?1Si93c7' �i'/1 �O ' ' //1//s9 SiC7di✓�.7 /Y/ cw,;71�voil�r� i(d�1a�7 / S;0�g F1 ��Zz 7,1 _ her /yb7d �o�d o�/��1a'�'.7 �-z/ z.�5 �,• �t.,s'rx�y� :. ��l��l YEN/ Yt/Y/ '• Z�/ 2L •F e •r: '7Vy %vY/ /tit'/ --7�7�J •: G lsio bars a�i h1o' -I? .. • ' 3Tofl..lt�1 t �y l r'"� .+4 6 �.J. � � j����•�tVls 1 G I C£i � N ccd6 �rJ / -j�,-yL•�.. \ � ��c Clc,�'� ��c � /�r�7y ���/mac =� 3v � /7 ='f � �� fi. �� is G�� ���. _ �/S•7�..s �l7'_.L.o ;4 Sg -2'T -2 .--3Sr7 -.!Id olY. .�/S74:7 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION/`y/��Co S �'G h� ��i`U SEWAGE# VILLAGE ASSESSOR'S MAP�B/c LOTIO 92 ow.4M33 O;J=NAME&PHONE Nth��C.X 21CV14 SEPTIC TANK CAPAC= /GOD C4I LEACHING FACILITY:(type) NO.OF BEDROO 3 BUILDER OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and teaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ap 33 5a� h4://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=099049&seq=1 12/20/2013 Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: 4 BUSINESS LOCATION: 1 A N S iTS MAILING ADDRESS: I b A .0 Mail To: TELEPHONE NUMBER: b _ Board of Health CONTACT PERSON: Town of Barnstable 1 P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: 926 - ( n Hyannis, MA 02601 TYPEOFBUSINESS: UC�C}A. Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO 7 This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents g Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS 2 3 OP. r 4l A BORTOLOTTI CONSTRUCTION,INC. e 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 41 508-771-9399 508-428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION / Property Address: Date of Inspection: 9(p Inspector's Name: Owner's Name and Address. CZ2 S/A- CERTIFICATION TAT M NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal �tems. The System: V Passes Conditionally Passes Needs Further Evaluation By the Local Aproving Authority Fails Inspector's Signatur . Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: A)TLEJA PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determned",explain why not. The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). 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 FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. ' The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100.Feet but 50 unless a well wat er analysis for coliform water supply well u Y Feet or more from a private wat pp y , from bacteria and volatile organic compounds indicates that the well is free from pollution ,s the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. a D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NDI due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply . The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: _Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. r/As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. ___,The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. ---All system components,excluding the Soil Absorption System,have been located on site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. the size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- i'1�. Y4t wt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) _j,fL he facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION i FLOW CONDITIONS RESIDENTIAL: Desi n Flow: — -g�Mons Nutuber of Bedroo s. __ Number of Current Reside nts: Garbage Gander: /VR Laundry Connected'fo System: /6:16 Seasonal Use. Water Meter Readings, if av ' able: Last Date of Occupancy: C•//fir?7/--- C()MMFR('iAi/i11tDi1STRIAi. /V Type of Establishment: Desg � Y Design Flow: gallons/day Grease Trap Present: (yes or no) : Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Last Date of Occupancy: Water Meter Readi ngs,s If Available: g , OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:. . / / / System Pumped as part Of1'nspection: if yes,volume pumpe gallons Reason for pumping: �V TYPE O-F SYSTEM: ✓peptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP OXIMATE AGE of all components,date installed(if known)and source of information: ewage odors detected when arriving t the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: tj Depth below grade: Material of Construction:k--'-concrete metal FRP Other (explain) Dimisions:.g 5' ,!�-' Sludge Depth: t;;)" Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 36 Distance from bottom of scum to bottom of outlet tee or baffle: 41006 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,ete.)� cZ Gt� GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP - Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: D Depth Below Grade: Material of Construction:—concrete—metal—FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert:&j2LX jZ4 l Comments: (note ' evel and distribution is al,evidence of solids carryover,evidence of leakage into or out of box,e c.) �� PUMP CHAMBER:J' G/ Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) _5_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type Leaching pits, number:LzLeaching chambers, number: Leaching gaileries,number: Leaching trenches,number, length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil, signs of hydraulic failure level o/ff pondin ,condition of vegetation etc.) _s - Sol °l 2VO4 CESSPOOLS:Ald Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: . Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. �1 , ,/ u.S'-C. T 33' 3o ' 0 DEPTH TO GROUNDWATER: Depth to groundwater: 2 1 Feet Method of Determination or Approximation: -7-