HomeMy WebLinkAbout0021 STONEY POND CIRCLE - Health 21 Stoney Pond Circle
Marstons Mills P
A = 064 068002
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Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Stoney Pond Cir. r
Property Address
POOL,RICHARD J&BERYL
Owner ;
information is �.
required for every Owners Name
page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information 13gOv
filling out forms
on the computer,
use only the tab Robert Paolini
key to move your Name of Inspector
cursor-do not Robert Paolini
use the return
Company Name
key.
h 67 Tanbark Rd.
It_ l Company Address
Marstons Mills MA 02648
City/Town State Zip Code
(508)280-9499 S14454
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 16.000); 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. R Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails s
f�
5/26/19
Inspector's Signa a 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 19
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
in the future under the same or different conditions of use.
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:
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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 19
r
i� Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
e 21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
Cityrrown 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ktlw"'�7 21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every MA 02548 5/26/19
a e.
Marstons Mills
P9
City/Town state Zip Code Date of Inspection
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:
C. Inspection Summary (cunt.)
❑ 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 weir*.
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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 19
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every Marstons Mills MA 02548 5/26/19
page.
City/Town State Zip Code Date of Inspection
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
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
ool
Liquid depth in cesspool is less than 6" below invert or available volume Is less
❑ ® than '/Z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 19
Commonwealth of Massachusetts
�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
City/Town State Zip Code Date of Inspection
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
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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:
t5insp.doc-rev.RM2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
❑ ® 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
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 19
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD 7&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
City/Town State Zip Code Date of Inspection
Sump pump? ❑ Yes ® No
NA
Last date of occupancy:
Date
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
3. 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:
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 19
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
11; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
5. Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
0 cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.System vented through the house vents.
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
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: 000 gallon
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
36"
1"
Scum thickness
t5insp.doc•rev.M 2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.. 21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every page. Marstons Mills MA 02548 5/26/19
City/Town State Zip Code Date of Inspection
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.Inlet and outlet tees are in place.No evidence of leakage.
D. System Information (cunt.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 19
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
ki�vv"'F`I
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
City/Town State Zip Code Date of Inspection
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has two outlet Iateral.No evidence of leakage.
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 19
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2/2 x40
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
D. System Information (cunt.)
11. Soil Absorption System(SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.no signs of hydraulic failure. Stone was dry at time of inspection.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 19
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19
City/Town State Zip Code Date of Inspection
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.):
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every
page. Marstons Mills MA 02548 5/26/19 .
Cityrrown 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
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 19
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every page. Marstons Mills MA 02548 5/26/19
City/Town State Zip Code Date of Inspection
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D. System Information (cons.)
15. Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
'separation from bottom of leaching 20'
Estimated depth to high ground water: feet
t5insp.doc•rev.7128Ro18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD 7&BERYL
Owner
information is Owner's Name
required for every page. Marstons Mills MA 02548 5/26/19
Cityrrown State Zip Code Date of Inspection
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:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
R A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Fw� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Stoney Pond Cir.
Property Address
POOL,RICHARD J&BERYL
Owner
information is Owner's Name
required for every page. Marstons Mills MA 02548 5/26/19
Cityfrown state Zip Code Date of Inspection
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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 19
- xt. SEWAGE INSPECTIONS '
LOCATION21 S.toncu Point Clacie DATE 10120103
VILLAGENa2,3ton,3 ASSESSOR'S MAP & LOT064-068-002
•INSPECTOR jozeph l. Macom9ea Ia.
SEPTIC TANK CAPACITY 1500 pa Honz
LEACHING FACILITY: (")Leachiieed (size)10,X40'
NO. OF BEDROOMS 3
BUILDER OR OWNER Znn i ro Stogie-
OWNER MAILING ADDRESS
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� , �,, ►1 �� TOWN OF BARNSTABLE �
LOCATION AG4 c'), S 1 SEWAGE # [ 3
VILLAGE
s .. � ASSESSORS MAP & LO
INSTALLER'S NAME Si PHONE NO.
SEPTIC TANK CAPACITY
III LEACHING FACILITY:(type) (s"
NO. OF BEDROOMS 3 PRIVATE WE L O�PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: - -3-7 -? 3
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No 6��
t
9 �� D!
s o
No.- ` ✓_ Fa$ ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratinit for Diripwial Works Towitrnr#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
........... � � S n 2. � cn 4r�`4------------- -------------------------------fib ---..... -------------•--------------------•-•---------
ocsfion-Address l n �r Lo)Na
...�s,1.ets .toe . C7!...5�ne., �"c�• t r e� e /�c��ice, ,n.!115
O�encr ress
11p1.e. -•-•-------------------------------------------------- --------- �3 P � cl -i l e=--..........
Installer Address
UType of Building Size Lot............................Sq. feet
—No. of Bedrooms______________ -------------------
Dwelling ..._Expansion Attic ( ) Garbage Grinder ( )
p`4 Other—Type of Buildings) .. .._._'_T o�of persons.......d2. ShowersCafeteria ( )
p" Other fixtures ............................... . .
---------------------------------------------------- -- q
W Design Flow..............3a�................gallons per person per day. Total daily flow------------- _I�.......................gallons.
WSeptic Tank—Liquid capa6ty.25MgalIons Length---------------- Width................ Diameter---.------------ Depth................
x Disposal Trench-- No. .................... Width___..--.__------.... Total Length.................... Total leaching area....................Sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by----- ------------------•--•-•--••--••....--•-••............-•••--•...... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................
pG ...........•----------------•.......---•-•••----•--•--•••••••..........................•••••..---•----•--•••-••-.......---...-•••--.....----------
.----------
0 Description of Soil-•-•-•---•------•-----------•.................•-•-•--•---------------•-•-•-•--•-•----------•---.....---•----•--••-•---•-•-------.....-•-•----.....••••••.......••---....
W ...-...........................................................................................................
�qq.� --po �..---------------• ....1-j
! -.-.✓ � �✓�eerS- ._.
U Nature of Repairs or Alterations—Answer when applicable----------------------1---__.___.... ..��.. _......
...........................................................................••--••------••-------•---...--•-•--••---•------------...------•--•-----••-•---............._..---..............-•••----......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complianaaeen issued by the board of health.
g � - _Si ned --- - -- ... .............................................. . .. �..
Date
Application Approved By ..... �... �-------------------------------
Dare
Application Disapproved for the following reasons: ..................... ......... ......................_................ —.... ........................................
k
....................................................................................................................... .................. ..- ......--.........------.............. .............-- - .
- _ - _ --- ................ ..................
Dare
Permit No. .... ...-.3...�.�---------------------------- Issued
Dare
^'1,r7"`.".w!'."".ram--.-^.--.�.—v-�... ..•..—.N•r..,�.... .+. w ...�:irSY^.�'.i�..y ...,•�«..ci7,.+ a...J'.':.3;;... �� _ ...�-. .r `_ ..�--.1....-...�......-..1....,..: _ F.._., .. �.. .� _y � .., ...r ��
kQ. . 9d vP �-
G� C�
NO../._..?:- Jl- FEz........[.��- e ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diri.pooal Wi orko Tomitrurtion Permit
Application is hereby made for a Permit to Co►lstruct ( ) or Repair ( ) an Individual Sewage Disposal
System at: (�
�� �ocation-Address l or Lo No,
.............................. �1 ^� 1Q.7..--r.-�^--c - t eq._�
ii ownerress(/�) l
c%............. c�� N ,��\ C \}°C -[--�-)•1 �--`�-...................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---...n......._..3______________.__.__Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building 5A J'kpA 11__`- No-of persons------ .:.............. Showers (J) — Cafeteria ( )
dOther fixtures ------------------------------- ----------------------------------- -•------- -------- ..............................................................
W Design Flow................. 3Q)................gallons per person per day. Total daily flow.............
95....................gallons.
WSeptic Tank—Liquid capacity_60T)galIons Length________________ Width................ Diameter................ Depth................
.x
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0-1 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Lz. Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................
a ...------•.....------•--....•-------•------------••........._•--- --------------------------------.........................................................
0 Description of Soil---...................... --•------•------------------------........--------------------.....---------•------------------..............................................
VW -------••••-----------•------•-•--•-----••--- ....................................................................... ----....
Nature of Repairs or Alterations—Answer when applicable,---------------�----e......._..__'1..1 i^ _ c,
------------•-...-----•--.._..----•--•----...-•------•--...-•-•----•-•--•---------•-----------------•------..----•
Agreement: .
' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance a een Is tied by the board of health.
Signed .... 4 '..-r... .......�7........ . . >-.
Dare
ApplicationApproved By ..... ......... ................................................................ ........................................
Dare
Application Disapproved for the following reasons: .... ... .................... ----- ..............................................---...................................
............................................................ ..... . .............. ............... .... ...... ...... ---- -. . .............................. ........................................
Dare
PermitNo. ---- 3-------3 5.>(---------------------------- Issued ........................................................
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�erttft.Ca a of 0110 pliaYICe
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by.. ................ ...... .. ............ ...................... ........_--.--------------------------------.....---__......___......._........_
at ..........�.�T..... .......: ... .. - .....
C ('J� . .....
has been installed in accordance the provisions of TITLE 5y�The States Environmental Code as described in
the application for Disposal Works Construction Permit No. ....../..,,3...-.._,3.6_4�... dated .....................
..._...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
_ L
.. .......__...._..... Inspector ............,..........................._._ ....... ............._. .. ............... i
----.------- ——————————---———————————---—————— ----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE /
Dispoal Workii Towitrurtion Permit
Permission is hereby granted..............................................------------•-•---------...---...----._...._................_....._............................
to Construct"or Repair ( ) an Individual Se age Disposal System
at ---- - •---
Street
as shown on the application for Disposal Works Construction Permit N�o 3—,1.3 __ Dated..........................................
-------------V•-Y-"`^' -••-------------------•-----•-•----••-----------------__.--
DATE..........�_-.d
nn-3.'.__.� ...........................•.......... Board of Health
--,-. _
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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AS BUILT: not to scale date: 9122193
lot# 2 S tone Po ncl Cr.
Town of: Marston Miiis
Septic pemi.93-336
Dwelling
1 2
A
7 3
r'1.
A to 1 = 17'6" B to 1 =37'6"
Ato2= 19' Bto 2 = 301
B to 3 =41'6"
A to3=37' Bto 4 =53'
A to4=42' Bto 5 =55'
A to5=46' Bto 7 =94'
A to =74'
105
DATE :10/20/03_--_
PROPERTY ADORE SS 21 Stoney Pond Ci2C.Pe
_ l�a2ht one 1�i2.��sL/7a•s�s. --- ��� �t� ��
MAP
-- 9Zb4�-----------------
PARCEL
On the above date, I inspected the septic system-at the above Laddress._____
Tnis system consists of the following:
1. 1- 1500 gaiion zeptic tank. RECEIVED
2. &ox.
3. 1-Leaching Zieid 10'X40'X1 ' NOV 1 3 2003
Baseo on my .inspection, I certify the lollowing condlllons:
F BARNSTABLE
4. 7hiz ie a tit-Pe dive be/2t.ie hyztem. ( 78 Code) T�WHEALTH DEPT.
5. The zept.ic .system i.6 in /12ope2 wo2king o2de2 at the
/22e,3ent.
6. Pumped Zep is tank at time o f inz/2ection.
SIGNATUR
Name _ _:_ _ P_ _MdCOmber_Jr ._ _--_
ompanY �4 �t2h _ M�S4m��C d_ Son, Inc .
^ 0Cf 5S : _ _@QX _�.6 ............
Cej),Se xLLLptja . _QZ632- 0066
P^•one _ _508 . 775_ 1338 _ __ _ _ -_-
TMIS CERTIFICATION OOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
T ink s•Cesspools•Leachflelds
Pvmped & Installed
Town Sewer Connections
P 0 Box 66 Centerville. MA 02632.0066
275.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:21 Stoney Pond C-.2c-Pe
aaz onz RiZZ.6, a.3.3.
Owner's Nameaan ice S o y e
Owner's Address: 10120103
ame
Date of Inspection:
Name of Inspector: (please print) 7o,6e/2h P. ('lacomgea a2.
Company Name:,j. P. Macomgea& Son Inc.
Mailing AddressQox 66
CE�`11 a 02632
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F 'Is
ellr
Inspector's Signature-
Date: id
The system inspector sh 1 submit a copy of this inspectio 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM - NOT FOR V T
qL _11�T�tk4 A.,,��,SS,'�fi✓: , 1 5
SUBSURFACE SEWAGE DISPOS�U, SYSJ'r; j I;\,SI'ECIIGN FOT:m
PART A
CERTIFICATIOo' (conGue f
Property Address: 27 Stoney Pond C.iacie
Na2zton�s
Ownerjan.ice oyie
Date of Inspection: 1--
Inspection Summary: Cbeck
A. System�Passes-
I have not found any information which indicates r.n t ,,
15.303 or Ln 310 CMR 13 304 exist. Any failure cri!rri,•: ny cv;iivamd arc vio.yd bo,, .
Comments:
7L? .�Lt ie �y�tem is in_�2oJze� wonk.ing onde2 at the
�n.5on imv_ -
B.
System Conditionnlly Panes:
One or more system components as dcwrioed 41 &C `Condit awd Pan ymho ( ki r,_„!;;•.;;
rcpaifed. The sys!crn upon eompodon of t}: ran 'r :( n Hard of Heakh,a _ b r n(
pass
Answer yes, no or not determined (Y.N,hT` in t3ie _ for ti,.! fcllc-io!i s;atcr.:rits. !!'"r t {r;crlr.inc' pl:a;c
C'' ;';41, -
The septic tank is metal and ov
er Cf 20 l;'..rS .'l:!' Or Go SCp'.:i: Ia71.>;t ('.i'�iC t':�ii.,
_!?C(1� n; t.•lh inir; '.'`, !::i?; .. ^,! filCi.]I a
'� in n ri or . . .,:; o i or .. hKV21, S' ter, :I
tank
S leplacd " a Cihll!)!)i Q 5•:.' ;(".d.'tk as r,Oji(0%2 by O ( 1kotn. r• .
n'c.' � .� i:i:' E! ass I 1 Tit
'-� `.i?,.. $G,: :): �i r ! S�CCi!:iil i. ..i )tC'�..'�'..ail:lJ .�...,?l:, :0; 1'Si.:'?� diiil is .. L�CiZIi•.,il. (..v:!1'
!:. !C'. img thm Q tw:pig IS Icy own 20 ':!rs pin ,<,
wOhscn•atlorl of % ,o
.[n.:C+id � � ?4i:`!.. ...•aip or 1':!<'?�•. G!!t Cr l':f',' Sl2•:.. `.Yd::( .:`•'Ci r'� ii;�: '!',..iD'.i;i;_,j? � �.., l:i NOW .. I
'.` pipeg) :r w !C a bro,:;n, S!itl.a Of lrrvcr .Ji nil'uko b iy�soln •.II `n`� ,' r - ,� '
1 �O:C. dSS li:Si;CCt10tl if ti4'lifl
2ppavy of Bond or Had&):
Obwo tion IS rcrt?Ov i
�i
—_ yVred ..� :P.�: g Too. Ann ti l,.i�,C$ i, lC;li .i it•: ._ iif�i i.:i. L1 i/V:t".;�:C•:1 iii;%�:�:1. l i'; y•, ;i:
r•_ s .:1s;;et t;vn if(•,,'ith .pprov.d of tiic B:;:,!d o! iltaWl1)
hrtl rn pipe(s)
is
ND
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 21 Stoney Pond Ci/tcie
¢2.s one .c 7 ¢76.
Owner: _ja ice Stoll e
Date of Inspection: 10/20/03 {..,..
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.
I. 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
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:
,00 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 I of a public water supply.
,(2 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 5 feet or more from a
private water supply well•'. Method used to determine distance f�
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other: 11��
3
Page 4 of 1 I ,
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A `
CERTIFICATION(continued)
Property Address: 21 Stoney Pond Ciacie
tlalt,Ttonz
Owner: lanilce Stouee �..
Date of Inspection: 70120103
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no" to each of the following for all inspections:
Yes No
` Aackup 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 Ag..rAa0 lb,*V ft
_ V Liquid depth in soespeol is less than 6"below invert or available volume is less than 'A day flow
I/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped / .
y 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.
Afty portion of a cesspool or privy is within a Zone I of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes ri //
!/tthe system is within 400 feet of a surface drinking water supply
v system is e system is within 200 feet of a tributary to a surface drinking water supply
�' the
y located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)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.
4
Page S of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM TNSPYECT'ION O :^•i
PART B `
CHECKLIST
Property Address: "'I Stoney Pond C.izc2e.
17 a2.3 T one 77 77 77, 77 7,3,3.
Owner: I an-ice=3--yU77e
Date of lospectloo: 3 e�;
Check irthe rollowing have been done.You must Indicate"Yes"or"no"as to each ore• e F
Yes l�
( Pumping in
formation was provided by the owner,occupant,or Board or Health
_ 2Werc any or the system components pumped'out in the previous two wcchs ?
L _ 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 p:.:-t
Were as built plans ofthe system obtained and examined?(Irthey were not w-.:;:Lic 1:�.c
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs orbreak out?
_ Were all system components,eluding the SAS, located on site ?
_ Were the septic tank manholes uncovered,opened,and the
or the baffles or tees, material of construction,dimensions,depth
Was the facility owner(and occupants irdirfcrent from owner)proviccd
maintenance of subsur(act.sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been d;ttn tic:' :s•:_'
Existing information. For example, a plan at Oic Bor_rd or Hc;�':ot.
✓✓/_ Determined in the field(rf any of the railure criteria rel.,ed C
is unacceptable)(310 CMR 15.302(3)(b)) +► ""'
o
S
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ,ot
Property Address: 21 S.tnfzai Pond
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):.1— Number of bedrooms(actual):
DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: I_
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system' (yts or no):a (if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use: (yes or no):
Water meter readings, if sy ilable (last 2 years usage(gpd))?O,')) = 4', 2 3. 29 yip
Sump pump(yes or no):Awat
2 = , g¢ .eo n s=7 6 7. 13 -PD
Last date of occupancy:
COMMERCLAVINDUSTRIAL
TM or establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design now(seatsJpersons/sgF%ctc.):
Grease np present(yes or no): J2,Q
Industrial waste holding tank present(yes or no):,�&
Non sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, iravailable:
Last date 6f occupancy/use:
OTHER (describe):_ ) ►
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped:i�� Ions •• How was quantity pumped determined?
Rcason for pumping:
T Y P OF SYSTEM
Scptic tank, distribution box, soil absorption system
BSingle cesspool
Overflow cesspool
2Privy
OShared system(yes or no)(if yes, attach previous inspection records, if any)
�Dlnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
/UDTight tank 'VVi Arucb a copy of the DEP approval
�dOthcr(describe):
Approximate a¢e of all co Hems, d e install (if known) and source of p ation:
Were sewage odors detected when arriving at the site (yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:21 S _or7-n_y 2nnr/ l'.L2cee
Owner: janice S ou�Pp-
Date of Inspection: i n i 2n i n
r-
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction:t0cast 'iron •d40 PVC4b other(explain): fib!
Distance from private water supply well or suction line: 2';,-
Comments (on condition of joints, venting, evidence of leakage, etc.):
�i,6 vented thnough .the Aoo/ vent,6.
SEPTIC TANK: 4zoocate on site
yet
Depth below grade:
Material of construction: concrete 4)c9metal ep—fiberglass,4)apolyethylene
,(Leother(explain) gO
If tank is metal list age:_�00 is age confirmed by a Certificate of Compliance (yes or no)N, (attach a copy of
certificate)
Dimensions: �1.6 '6i4�� d�e�•tl/ �7�/!"
Sludge depth:--0
Distance from top of sludge to bottom of outlet tee or baffle: Q
Scum thickness: 0 _
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee�or baffle: _
How were dimensions determined: /l?��Szm?e s
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pump b2/2tic tank QlJP2U 2- 3 g�Dnf7A jnPel R n77f0pf 4ppA inn in
,?.Pory The tank 1� ,s:tz7ectultai-eU .so%tz.-L '��d .t owi nn p,i),idPnry
o;° 2eczkage. N.
GREASE TRAP,I<"(locate on site plan,)
Depth below grade:e4
Material of construction:d4 concrete,�Lmetal.f fl fiberglassX_4polyethylen&0 9 other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet fee yr baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: AJ
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of 1 I '
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C 11
SYSTEM INFORMATION(continued)
Property Address:21 Stoney Pond C-.2cPe
Plnn.��_nn�s 17.i.P.P.s. l'1u4.�.
Owner: �rjnira .Ctnul/o
Date of Inspection: _1 o )o l o 3
TIGHT or HOLDING TAN (tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: 44
Material of construct concrete d&meta l,f0_fiberglass,4Y—polyethyIene�rP other(exDlain):
Dimensions:
Capacity: gallons
Design Flow: i _gallons/day
Alarm present(yes or no): A�4
Alarm level: zo,74 Alarm in working order(yes or no): e!/
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
Tig o2 hoiding tank,3 u2e riot plieTsHT
DISTRIBUTION BOX: y (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:AL
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.):
(7•ik Liz v_D./rL;Ln, Lbx,- 'n_.t IL)n - l i.Q A6 - e , dLzCI- O,�� iSO Q:Gd4 Ca22q
Ouea_ Nn p»ir/pnro 2- Q` p�age ,into o2 out of �he 9oX
PUMP CHAMBEPA&/C-<locate on site plan)
Pumps in working order(yes or no): XJ.
Alarms in working order(yes or no): ,V2
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Puma rhamPpn i.t nof pAg,6gat.
8
P.! 9 C.f I I
OFFICIAL INSPECT[ON F(-)I I — N OT F 0 1 N"0 1 i IJN'T 1A.I t Y' A 1, S 1--, 1'S
sl'..\VA()*E DISPOS.AL , YSTI'-M INSPI (-"T[ON FORM
PAIRA, C
SYSTEM INF70RNIATJON
PropertyAddress:21 Stoney Pond CiAcie
0)1 n c r: anima
Ditte of hispvciiuril Of ZOf 03
5A-S): ..,/locate ou site pk(ll, CXCaO'Miofl MW fcquireu)
Lea chZj
%A
Loea-te-d,... See page- ........—... ............ ........
T\pe
Da !ra fl,-,f 1)t)'-,
k.;I C1.1 a I i C I i c', i,U;I,. C I
.........XJ-
L.qqAy Viand to medium dine .sand No zignz of hyd"lau'e-ic "a'iiuAe
............... . .......
ge ation i,3 no/zma—p. ...
anc! coi)f'!gura.lQ'I'.
:J i
U!:
d�Clriti':�: 1:1 f I
S
................ ........ ..........
----------- ------ ...........
PRIV)A&,�@�'Iocate un
Mcer:; is ofcoriskru
mv ii si a in:
Uf:Qtil 01 S011--
D
............. .............. .............
Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 27 Stoney Pond C.i2c.ee
aa.6 on.a 7777.3, Pla.sa.
Owner:aanice 3toyie
Date of lnspection: 3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
I �
II
a s�c N Q. �e� a ►`GLCI
10
Page I I of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(continued)
Property Address: 21 Stoney Pond Ci/tcie
a/zz onz Niiiz7azz.
Owner: lanice Stouie
Date of Inspection: 1012010 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water ID6 feet
Please indicate (check) all methods used to determine the high ground water elevation:
q6SObtained from system design plans on record - If checked, date of design plan reviewed: 1012010 3
ESObserved site(abutting property/observation hole within ISO feet of SAS)
Checked with local Board of Health-explain: A,t P uLU
Chccked with local excavators, installers- (attach docurnentation)
LSAccessed USGS database-exp lain:hY- Rt//town. ja znztaUe. ma, u-6.
You must describe how you established the high ground water elevation:
eed: Gah2etu R Niiee2 Mode.P 12/16194 gzound wate2 eJeLat-ions agove 6ea eeve2.
aed: US9S;09.3onUat.ion wee.P data tune 1992
aed: ILSa.S:TorhnirnP Pu 000 1 In Tito #2 Rnnuae aanaez 01 craound wate2
Ledche-'.ie.Pd
10'X40'
a.b .eet
.. Ground wat t=cct Below Bott om 0f Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
f
• Therefore, the vertical separation distance between the bosom
Of the leaching pit and the adjusted groundwater table is r
feet.
11
,wan r.—n r•r,T-r�•w-ww•n�r�.n rw�.a�rsrrtiw+r•w►r�w+.rwn n�+►y nnr�n+...wn
TOWN OF daan.eta&-Re BOARD OF 11EALTl1
SUBSURFACE SEWAGE 1)151`OSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
^•rn-7••,•ttr-r.rra-.�rnlnRn,lfwrwJRrr7w'rwnr Cl-'1VwP17rwwP'1'�1R�w0�^wr� twn •.+vP•r• r--i• •�.
-TYPE OA PAINT CIrEAALY-
PIlOPERTY INSPECTED
STREET ADDRESS 21 Stoney Pond Ciacie Naaztonz l'1.iiz, Mazz. '
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Ian-ice Stoyie
PART D - CERTIFICATION
NAME OF INSPECTORJ_oseph P.Macomber Jr.
COMPANY NAME J P Macomber & SoR Ind.
COMPANY ADDRESSBox 66 Centerville Mass . 02632
Strut Tovn or C ty Stat• 1P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system nt
this address and that the inrorination reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
</ System PASSED ,
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
heRltll or, the. environment as defined in 310 CMR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con cted has found that the system fails to
Protect the E-)tlblic health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA. of this inspection form ,
Inspector Signature k:2Date
n copy of this c rt.ification must be provided to the OWNER, the BUYER
Oe
Where aypl ioable ) and the BOARD OF HEAL'1'll.
* If the inspection FAILED, the owner or""operator shall u
within one year of the date of the inspection , unless allowed dortrequiredm
otherwise as provided in 3.10 CFjn 16 . 306 r
partd . doc