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0106 TUPELO ROAD - Health (2)
106 Tupelo Road, Marstons Mills ' A=057-104 0 �` i t_ asp - ia� Commonwealth of Massachusetts p Title 5 Official Inspection Form r : Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /O u 162 Property Address Owner. Owners Name l ✓ in g formation is r s h //s O)6 required for every ' page. City/Town State Zip Code Date of Insp ction 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 1 f atio 51 353: - filling out forms on the computer, 7a V ao use only the tab key to move your Name of Inspector cursor-do not � use the return Company Name —key. `//C� S7 Company Address Z—qs1� R City/Town � n State n Zip Code O- a�o - � 7 aL- Telephon Number j 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 sy 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Ile Inspector' 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 18 i I cam, Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 06 / (A Ut/o Property Address a rrM Owner Owner's Name ) information is rsLOhs (1) 6 K /C" / required for every page. Cityrrown State Zip Code Date of I pectin C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P s: 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.7262018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r` /L Property Address ct Y H'I Owner Owner's Name information is A f s1 N �f• ©�6 l�� �p� hct 1required for every 7v page. CityfTown State Zip Code Date of Ingpectidh 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): broken or obstructedpipe(s).The ❑ The system required pumping more than 4 times a year due to 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 1 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /D U �o Property Address Owner Owner's Name information is f -5 required for every page. Cityrrown State Zip Code Date of Inspeoflon 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 ❑ ckup of sewage into facility or system component due to overloaded or ;/-�Z! clogged SAS or cesspool El 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.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �. p Title 5 official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T�-Iae lo 1�2d- Property Address arv'� Owner Owners Name information is � required for every `C page. City/Town State Zip Code Date of 14pectidh 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 ❑ [Ej/ Liquid depth in cesspool is less than 6"below invert or available volume is less /than 'h 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. ❑ U1 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 nd chain of custody must be attached to this form.] ❑ 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 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.M62018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I i Commonwealth of Massachusetts Title 5 Off icial Inspection ection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U e/L7 Property Address 61 Owner Owners Name 1 r,/� information is Q r s ,,JS V Od 6 7 0 /a- & required for every page. Cityfrown State Zip Code Date of I 1pecli n 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 ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 L I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name 1 required for every TC40'-S40'1; A/4— nformation is page. City/Town State Zip Code Date of In ecti dn D. System Information 1. Residential Flow Conditions: Number of bedrooms Number of bedrooms(actual): (design): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �d 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 Noo Seasonal use? ❑ Yes [�No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No CCAL ize / Last date of occupancy: Date t5insp.doc-rev.V262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I Commonwealth of Massachusetts �e Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is �s-�o✓ts S D�1b�� /p� / U required for every page. C State Zip Code Date of Insp lio ity/Town n D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: r 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .% �utee lo- Property Address �M Owner Owner's Name information is O����required /�- for every page. City(rown State Zip Code Date of In ectio D. System Information (cont.) 4. Type of S em: 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/Altemative 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 alomponen , date installed(if known)and of information: Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): % Depth below grade: feet Material of constructi;'40 ❑cast iron PVC ❑other(explain): /O r Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 18 l Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42c� Property Address Owner Owner's Name information is N S �a 6 /L required for every A✓ 0 S page. City1rown State Zip Code Date of Ins ectio D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet :eri f construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 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.): c t r/h i vl ✓101'- !/I-e�c�e�✓ �N� (✓� zI 00 60'1 c' r7l o h r /v —4-G t5insp.doc•rev.726f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 'N f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 tae/a 12d Property Address M Q l� Owner Owners Name//// information is I &V i9d-6[f required for every Q r Ns page. City/Town State Zip Code Date of Inspe tion D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.728/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Property Address l�l G dti Owner Owner's NamA information is required for every page. Cityrrown State Zip Code Date of Inspbction D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): So/ rls AA2 t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Y Commonwealth of Massachusetts Tale 5 Official Inspection Form iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (,f Ae to R Property Address Owner Owner's Name l information is i�d /� required for every n page. City/Town State Zip Code Date of I pectin D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS no:located, explain why: Type: 00 /O ❑ leaching pits number: ❑ 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 r Commonwealth of Massachusetts �o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Citylfown State Zip Code Date of Ins otion 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.): f4o kle a 0 .CC), r4?C, h a 1 - , A l2. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 06, Property Address I NG✓vl'I Owner Owner's Name information is G�r/f 0A1 / A114 required for every page. CityfTown State Zip Code Date of In ection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -7 U /o Property Address ^ / Owner Owners Name1111,91-5.�fs / yinformation is /v required for every page. Cityrrown State Zip Code Date of Ins# ction D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a vie f the sewage disposal system, including ties to at least two permanent reference landmark r benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the bu' Ing. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Q isoo 4 /1 cZ -- 33.6 9J�— Y l 1+3 -3� 97"53 I t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntaryy Assessments Property Address Owner Owner's Name [ � information is art 7�^f / od' � (3 ��" /� required for every page. Cityrrown State Zip Code Date of Inspegfion D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells f- �/b kj�' Estimated depth to high ground water: 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) Check d with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must descri ow you established the high ground water elevation: — (A C, C.N clG 4 5-9 /0 C 4;-je V l I •�1 0 �t vt c vC-1� I Before filling this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 u e /O gC Property Address armor Owner Owner's Name information is required for every page. Cityrrown State Zip Code Date of Insp lion E. Report. Completeness Checklist Complete all,applicable sections of this form inclusive of: ff"A. Inspector Information: Complete all fields in this section. LK CB• Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ilure 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.MW018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 z Jun 23 2016 21:25 Jim The Inspector Man 5085349919 page 19 L9 0 Commonwealth of Massachusetts E Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IND r' 106 Tupelo Road Property Address t-+ Margaret Casey s Owner Owner's Name information is Marstons Mills l/ MA 02648 6-20-16 1:: required for every t..o 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. Fti Important:When A. General Information / /�� ��N��t►ttmitq,,,,,� filling out forms �d OF j, on the computer, `� ...•. . use only the tab 1. Inspector: key to move your 3 JAMES N cursor-do not James D Sears =a• S imwR use the return Name of Inspector Y• �,4 Capewide Enterprises, LLC — 1� I7 �T7T—�G j���Z as Company Name i����O�F 5 I N Sp 153 G `\\�� ommercial Street ��arnn�tnmllkol Company Address » Mashpee MA 02649 CitylTown State Zip Code _ 508-477-8877 S1623 Telephone Number License Number t 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails . r ❑ Needs Further Evaluation by the Local Approving Authority 6-21-16 : nspector's Signature Date s F 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 should be sent to the system owner and copies sent to the F_ buyer, if applicable, and the approving authority. is ....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. G. t5ins-dcc-rev.6116 Title 5 Officia Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1T /_p VS f Jun 23 2016 2125 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts '? Titlew 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - - ; 106 Tupelo Road Property Address Margaret Casey Owner Owner's Name information is required for every Marstons Mills MA 02648 6-20-16. page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) - Inspection Summary: Check A,B,C,D or E/always complete all of Section D , A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and five infiltrators. Note: Zable filter in out let tee. - k !l!- t I, 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 t 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, f 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. k' "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. r r ❑ Y- ❑ N ❑ ND(Explain below): i t t t.. 1� f t t5ins.doc-rev.6118 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 F Jun 23 2016 21:26 Jim The Inspector Man 5085349919 page 21 r i. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments £; F '= 106 Tupelo Road Property Address Margaret Casey Owner Owner's Name E_ information is required for every Marstons Mills MA 02648 6-20-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if v pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due c 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): n. E ❑A distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): `= E L ❑ 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): f ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): F F. • i' • 5 L 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. l S 1. System will pass unless Board of Health determines in accordancwwith 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.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r` F C•' 4 is r.. Jun 23 2016 21:26 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Tupelo Road Property Address Margaret Casey Owner Owner's Name. information is required for every Marstons Mills MA 02648 6-20-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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 I_ supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water e 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. l 3. Other: p E i F. F t- iFF F. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No = C' ® Backup of sewage into facility or system component dueto 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 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in SHOW is less than 6" below invert or available volume is less than %day flaw,L E14CIIINO P ISins.dac•rev.6/16 Title 5 Official Inspection Form;subsurface Sewage Disposal system•Page 4 of 17 f". i Jun 23 2016 21:26 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Tupelo Road Property Address Margaret Casey Owner Owner's Name information is 5_ required for every Marstons Mills MA 02648 6-20-16 page. Cityrrown State Zip Code Date of Inspection e E- B. Certification (cont) Yes No F„ ® 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 d_ tributary to a surface water supply. is ❑ ® 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 F. 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 2000gpd- 10,000g pd. ❑ ® 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. 4'. 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. 5 4 Yes No i'- ❑ ❑ 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 f. C ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection E Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered.a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large i 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. 15ins.doc-rev.5116 Title 5 Ofriciai Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 e. Jun 23 2016 2126 Jim The Inspector Man 5085349919 page 24 F" is Commonwealth of Massachusetts Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Tupelo Road Property Address Margaret Casey - Owner Owner's Name F information is required for every Marstons Mills MA 02648 &20-16 page. City/rown State Zip Code Date of Inspection F. C. Checklist v S.. 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? L F' ® ❑ Has the system received normal flows in the previous two week period? E ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? 2 ® ❑ Were as built plans of the system obtained and examined? (If they were not tv available note as N/A) = ® ❑ Was the facility or dwelling inspected for signs of sewage back up? r ® ❑ Was the site inspected for signs of break out? E: ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank r inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ® 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. t, ❑ ® 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)] t: D. System Information Residential Flow Conditions: r Number of bedrooms(design): 4 Number of bedrooms (actual): 4 ° DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 i. r: s t5ins.doc rev.6116 Tide 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 6 of 17 i_. i' Jun 23 2016 2126 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Tupelo Road Property Address Margaret Casey Owner Owner's Name information is required for every Marstons Mills MA 02648 6-20-16 page. City/Town State Zip Code Date of Inspection s D. System Information Description: The system is a 1500 Gal. Tank D Box and five infiltrators. f t- Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No i information in this report.) t Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 000Gal r_ Water meter readings, if available(last 2 years usage (gpd)): 2014-142, y, 2015-185,000Gais Detail: t e e. Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Y Commercial/industrial Flow Conditions: , Type of Establishment: I k.. Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: G t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r: Jun 23 2016 21:27 Jim The Inspector Man 5085349919 page 26 E. e t Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Tupelo Road - Property Address Margaret Casey e Owner Owner's Name information is Marstons Mills MA 02648 6-20-16 required for every - page. Citylfown State Zip Code Date of Inspection E D. System Information (cont.) Last date of occupancy/use: `= Date = Other(describe below): C General Information Pumping Records: c Source of information: NA `. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons t. How was quantity pumped determined? s r= 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 t. maintenance contract(to be obtained from system owner) and•a copy of latest i inspection of the IIA system by system operator under contract ❑ Tight tank, Attach a copy of the DEP approval. G ❑ Other(describe): i ; t5lns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Y E 4 Jun 23 2016 21:27 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form t F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k ° 106 Tupelo Road t Property Address Margaret Casey r Owner Owner's Name information is Marstons Mills MA 02648 6-20-16' required for every F; page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r F Approximate age of all components, date installed (if known)and source of information: 1998 Permit# 98 -73. t Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2611 feet Material of construction: t F- t. ❑ cast iron ®40 PVC ❑ other(explain): I. Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. r Septic Tank(locate on site plan): x - Depth below grade: 16"feet Material of construction: 4' ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Y' E Z 4 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 4, Dimensions: 1500 Gal. Precast H-10 i Sludge depth: 2" t5ins.do •rev.6/16 Title 5 official N speaion form:Subsurface Sewage Disposal System•Page 9 of 17 • e i'. Jun 23 2016 21:27 Jim The Inspector Man 5085349919 page 28 t E Commonwealth of Massachusetts Mom Title 5 Official Inspection Form F e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' i- 106 Tupelo Road Property Address Margaret Casey Owner Owners Name information is MarstonS Mills required for every MA 02648 6-20-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) E Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 c it r 1" Scum thickness e t Distance from top of scum to top of outlet tee or baffle 8 is Distance from bottom of scum to bottom of outlet tee or baffle 17" t_. How were dimensions determined? Asbuilt-Tape ` Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, yt liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 16" below grade. Inlet tee, out let tee w/filter. No sign of leak age or over loading. F Ix C v r t: Grease Trap.(locate on site plan): Depth below grade: feet E' Material of construction: ❑ concrete ❑ metal ❑fiberglass g polyethylene. ❑ other(explain): i^ Dimensions: c: L: Scum thickness Distance from top of scum to top of outlet tee or baffle 4_ Distance from bottom of scum to bottom of outlet tee or baffle t' Date of last pumping: Date ISins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 10 of 17 I: Y � Jun 23 2016 2127 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts ` Title 5 Official Inspection Form r- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Tupelo Road' r Property Address s i4 Margaret Casey E' Owner Owner's Name information is required For every Marstons Mills MA 02648 6-20-16 page. Cityaown 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): j fi Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: `~ gallons . Design Flow: 4:. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No c r Date of last pumping: Date t f_ Comments (condition of alarm and float switches, etc.): - r a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No s; s t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 or 17 Jun 23 2016 21:27 Jim The •Inspector Man 5085349919 page 30 F is Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � f 106 Tupelo Road Property Address Margaret Casey Owner Owner's Name information is required for every Marstons Mills MA 02648 6-20-16 _ page. City/town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): r 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.): z D.Box is 16"x16"-2' below grade. Box is clean and solid w/one line out. No sign of over loading Y. or solid carry over. fi r E f Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): E- 5 iE n. Y * If pumps or alarms are not in working order, system is a conditional pass. E i Soil Absorption System (SAS) (locate on site plan, excavation not required): E: If SAS not located, explain why: e e C 15ins.doc o rev.6116 Title 5 Offidd Inspection Form:Subsurface Sewage Disposal System•Page 12 or 17 r C t. C f E I Jun 23 2016 21:27 Jim The Inspector Man 5085349919 page 31 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 106 Tupelo Road Property Address i Margaret Casey Owner Owners Name information is i required for every Marstons Mills MA 02648 6-20-16 i page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: i' ❑ leaching pits number: i ® leaching chambers number: 5 ❑ leaching galleries number: f ❑ leaching trenches number, length: ❑ leaching fields number, dimensions; ❑ overflow cesspool number. t ❑ 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.): ; Leaching is five infiltrators. CK D Box and camera out to chambers. Probe above and beside chambers. No sign of over loading or solid carry over. 7- i. t 1 t, Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert l" Depth of solids layer Depth of scum layer F Dimensions of cesspool Materials of construction ' Indication of groundwater inflow ❑ Yes ❑ No t. t5ins.dac-rev.6/16 Title 5 OKcfal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t r i I E Jun 23 2016 21:27 Jim The Inspector Man 5085349919 page 32 F' t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1, 106 Tupelo Road Property Address 1 Margaret Casey ` Owner Owner's Name information is Marstons Mills MA 02646 6-20-16 �. required for every r. page. CitylTown ' State Zip Code Date of Inspection D. System Information (cant.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).- Privy (locate on site plan): i f Materials of construction: Dimensions 4 r : Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): li t ; i. I' r t l (� 1 i 1 i' I I , ti F 3 i . � 1 15ins.doc•rev.6116 Title 5 Official Inspection Form;Suhsuraca Sewage Disposal System•Page 14 of 17 i' i : Jun 23 2016 21:28 Jim The Inspector Man 5085349919 page 33 J: . • f I. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments E ? 1 106 Tupelo Road Property Address Margaret Casey is Owner Owner's Name required for is every Marstons Mills ° required for eve MA 02648 6-20-16 page. CitylTown State Zip Code Date of Inspection 1 D. System Information (cont.) . ' F 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 r t. R EAk JB Ee K --� a-1 - .2 -AZ2 028 � 3 + 3 q 36 1'- e T 1 i i' i i I C tSins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 e_ t Jun 23 2016 2128 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form, i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Tupelo Road Property Address t Margaret Casey Owner Owners Name information is MarStons Mills ' required for every MA 02648 6-20-16 page. Cityr'Town State Zip Code Date of Inspection t D. System Information (cont.) Site Exam: Ff F ❑ Check Slope E: i ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth high ground water: 12+ - feet Please indicate all methods used to determine the high ground water elevation: ; f A. ® Obtained from system design plans on record ` If checked, date of design plan reviewed: 4 Date e ❑ Observed site (abutting property/observation hole within 150 feet of SAS) r ❑ Checked with local Board of Health-explain: Y. F ❑ Checked with local excavators, installers-(attach_documentation) 1 ❑ Accessed USGS database-explain: f 1. You must describe how you established the high ground water elevation: Old T.H. 4-1-82 No G.W. at 12'. Bottom of chambers at 8' above T H Depth ( r S. I T I i Before filing this Inspection Report, please see Report Completeness Checklist on next page. f, 16ins.doc nsv.6116 Title 5 OHiciad Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Jun 23 2016 21:28 Jim The Inspector Man 5085349919 page 35 t Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Tupelo Road Property Address Margaret Casey r. Owner Owner's Name Information is Marstons Mills MA 02648 6-20-16 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked l ® 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 w i' L i` I° t F t IH E i I' t t i i- t5ins.doc-rev.6/16 - Title 5 Official Inspection Form,Subsurface Sewage oisposal System-Page 17 of 17 � F i a ' I: r.. is Sharma,Rajeer 106 Tupelo Rd CONTRACT Customer Name_ Marston Mills,MA 02648 Customer Signature < SKETCH Contract Date 703-623-5150 Sales Representative Signature 2.,1100 ATTACHMENT Customer Phone_ Contract Price 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23_..24 25 26 27 28 29 30 31 32 33 ..39- 35_� -37 - 39 40 41 42 43 4a 45 46 47 48 49 50 51 52 53 591 55 561 57 58 59 60 a 0 2 - 3 _ '}_ o _ ___— 4 —_ — - — -- 6 — - -- -- -- ---- ------ r - --- L 9 10 11 12 13 14 5 r 16 IFF --,MSi 1Sir I.__(r w LL I 2,22 ! --- -- -- -- —' - -- - -- I 29 24 l f — '. rZY tr 8 21 27 28 29 _ - - - — -- j 30 P 31 AU Oa 32 35 NOTES: PUV 6r(-ow,x7orcl. w-,Qs c-4t Each box equals one foot unless otherwise noted.This sketch is a good faith representation of the work to be done, it is understood that all dimensions derived from this sketch are approximate,and that all locations of outlets,light fixtures,plugs,jacks and/or switches are subject to change if necessary. ' . TOWN OF BARNSTABLE LOCATION ®6 ��1,d��D> /� SEWAGE # ?Sr'2.3 VILLAG ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) r��1h9/&< ��� (size) "Vo.C, NO.OF BEDROOMS BUILDER O OWNE 625 el PERMITDATE: 2���� 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) j Feet Edge of Wetland and Leaching Facility(If any wetlands exist ` Feet within 300 feet of leaching facility) Furnished by (7 3b 333��' F ' - 53 7 f0 No. Fee ! y� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPrication for Zizpogar *rgtem Cow6truction Permit Application for a Permit to Construct / pp ( )Repair(✓)Upgrade( )Abandon( ) (]Complete System Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. r 4(fee/o Ad, P6vy/ �- Oel Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Af Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(--to Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures LL Design Flow 1 lW gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Xl&)'/�9 Type of S.A.S. 3- Description of Soil Nature of Repairs or Alterations(Answer when applicable) ���-/�° z� J��%% �1� /-tp Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this oar of He th. Signed Date �Q Application Approved by Date Application Disapproved for the ollowtng reasons Permit No. ' 7 Date Issued 6 7 _ ia � � No. / [/ -.:d.wr Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Digaaf *pgtem (Longtructton Permit Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No. /®/ �F- D O Owner's Name,Address and Tel.No. Assessor's Map/Parcel 4 Arlw* Installer's Name,Address,and Tel.N Designer's Name,Address and Tel.No. �rJhG��% 7 71) f Type of Building: ,r1 Dwelling No.of Bedrooms l Lot Size sq.ft. Garbage Grinder Other Type of Building /e51 e, ee No.of Persons Showers yp g ( Cafeteria( Other Fixtures Design Flow (� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 'X/9���� �S��1' Type of S.A.S. Description of Soil y© ITZ Nature of Repairs or Alterations(Answer when applicable) / Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Codehd not to place the system in operation until a Certifi- cate of Compliance has been issued y this o`�j of H 1th. 11 Signed AOWI� Dated/ ,_?/9T Application Approved by `?� D't Q_-I- r/ Application Disapproved for the following reasons i Permit No. _3 Date Issued t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CE TIFY, tha the On-site Sewage Disposal System Constructed( )Repaired(� ) Upgraded( ) Abandoned )by �OI�yOF G©/?cJJ'� at al �U ��© rG✓ has been constructed in accordance with the provisions o Title 5 and the for Disposal System Construction Permit No. g - 73 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 1 ZZ Inspector f�+4 V ----------�--------�� No. s( a/�'"� Fee o�, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwizpozal *pztem(Construction Permit - - Permission is hereby ra/�ted to Constr ct( ) pair( )Upgrade( )Abandon( ) System ocated at lDO KW_/a /��j'gJ�d7�► -�//�s and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pen-nit. Date: " a ! Approved by �• Z/ t o/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated /�Z���� , concerning the property located at /D6 ����� �� �/�10Iv`�®�J / i� meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility ere are no private wells within 1-40 feet of the proposed septic system There is no increase in flow and/or change in use proposed 1There are no variances requested or needed. v If the propose Y d leaching facility will be located within 150 feet of any wetlands, the bottom of the • proposed leaching facility will =be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) 4,3'-5 _ B)Observed Groundwater Table Elevation(according to Health Division well map) Z� SI GNED :: DATE: 1/ZS`I LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:art Qa �^1 bit J W II i Q i = TOWN OF BARNSTABLE . LOCATION ��6 ��idZ'`D /�G� SEWAGE# SI''73 VIL;LAGB/00-MI2 /Pi/A ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /.S 00 'ad LEACHING FACILITY: ( ) T /t' f (size) le jc Sao Xil � typ e •O:'�OF BEDROO MS N. B:UII:DER O OWNE A1-- 5r- �4Sey PMMITDATE: 2 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility st Feet Private Water Supply Well and Leaching Facility (If any wells exist pn.site or within 200 feet of leaching facility) Feet Ed e'of:Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i r[ A � /1 I `ASSESSOR'S MAP NO.� 7 PARCEL j oly LOC-� ION �� SEWAGE �_ERNIIT NO. 0 ', � ROW VILLACE �I STALLER'S NAME A ADDRESS K o l-f l� UILDER OR OWNER DATE PERMIT ISSUED �`�_�� DATE COMPLIANCE ISSUED .7 - .1 ^a7 t ASSESSORS MAP NO:_ 1< 7 PARCEL NO: /v -- 11 Fizz THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................O F................................_...... Appliratiun for Diiivuua1 Works Tonstrnrtiun ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1-10 ----- Location .... ..V11.....SIN I . i -Address Lo No. � t ----- -"'•••-••--..._..-•---•-•--•-••- ------------- ----••---•-----.� 'aiv.. _t. ............................................ Owner W Addre ------ jo� • ••-•-•-- n:�V� -rya� ------------------•--------- ---------- .- Installer (� Address Type of Building Size ......Sq. feet �-, Dwelling—No. of Bedrooms_-------------••--•_..___.............Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building 04 a Other fixtures . ...............................No. of persons................../._.e_i:. Showers ( ) — Cafeteria ( ) d W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.,&.�n'..gallons Length.........P.... Width...... ..._ Diameter________________ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_______•---__--._---sq. ft. 3 Seepage Pit No-----------_------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by............................................................ Test Pit No. 1................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........................ P4 ---------------------------------•-•-----•-•................................................................................................................ 0 Description of Soil........................................................................................................................................................................ x 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'TTl.m. p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued by e boa>d of lealth. Signed--_..... / _�! •••.Y - • -•...... Da e ApplicationApproved By............ .... .. -••------•------------------•---------- ---------------------------------------- Date Application Disapproved for the following reasons----------------•--------------------......--•----------•----------..._`-,....................................... -••---•....-----•.............•••.....-----•-•--••-•-----•-••-•-••-----•--•••-----------•-...--••-........-•----•-----•-.....----••-•----•••---•----•-----------•---_.........---•-----------•----------•- Date PermitNo.... - ..................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---- .. ..............OF.........................................------------------.....................-----•--•- AVplirFation for Disposal Works Tomtrurtion Vvrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 0--7:_Y......TYA11c).....Td---------------------------------------- ................................� nx...... Location-Address Lo No. .169ta!�.... 1N ....---•-....------•-----•-----------•-•-----•---------- ---•••--•--...: � s w �.1_S ......................................... ner Add s a ----..... -�-----C9wim' &.V.q/............................ --......... s� . ..&..... d .................... 17 Installer Address dType of Building Size Lot_A-06------------Sq. feet U Dwelling—No. of Bedrooms................... .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ._ No. of persons.................�........ Showers — Cafeteria Q' Other fixtures -------------------------------• - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity4b.!n'...gallons Length........_r..... Width......5-1------ Diameter................ Depth................ 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........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---_------___-__---__--. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------•--------------------------------------------------•---..............---•---•--...--•-•••---......................................................... 0 Description of Soil........................................................................................................................................................................ x W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ••--------------------------•------------------------------•------••-------------------.............------.....---------------------•----------------------------------------------------._.........---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iTTt.;, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued by h boa d of iealth. � t Signed....... ................................... --....Vtyva?...... � Application Approved By........... ._..��. . .--..... Date Application Disapproved for the following reasons:............................................................................................................... •--------------------•------.........-•-......_..•---•••-------------•--•-•---•------...................-'--•--•-----------•----------------------------•••-•----•-•-•--••-••-••----•--••---------------- Date PermitNo.... 7 ... ---------------------- Issued---------.......-----------------••----•-------•----... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... . '.L! '1...........OF........��i, cxr�aa E?:e!. ...................................... Trrtif irat a of ToaatpliFanre THIS IS TO C13RTIFY, That the Individual Sewage Disposal System constructed oC) or Repaired ( ) by �.. ` ... 'C.. ( 'ter.. ....... --•--•--- Installer at------.... r -••-• --------�--a........................................................................................................................ been installed in accordance with the provisions of TTTIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----2-7_--:�---------------- dated-...-_.--_.-.--_--_-._-_..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YNE SYSTEM WILL FUNCTION SATISFACTORY. ^.. .. .DATE....................�..�.........[ . ��.................................--------•-------- Inspector---------- --- ----40-- - .....-............................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �If NO..�'. • Disposal Works Tuonotratrtion Trani# Permission is hereby granted-----0�( �rx! - f-----------••--------•----------------------------------•-------.......----•-.... to Construct (>O or R�air ( ) an dividual Sewage Disposal System atNo......,.,:i.1 � ------n-4�-...................................-•-----................................................................................ Street as shown on the application for Disposal Works Construction Permit No,?.?ov.t Dated.......-f...:_�.�r!..:._��...... Board of Health DATE................ 7------•--•-------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS p0 ' 1 �3,561-s,F a t.9 �1pro -_ L 1 q qx N f /OO �_ 3 0 � ' c s 1 I 0 D< \""'N_ "�j Ivd •� I f LEGEND EXISTING SPOT ELEVATION OyQw PATH OFMq PROPOSED SPOT ELEVATION �Q QJ ��� ss�� �N\ V Agri EXISTING CONTOUR ---0- -- P A U L PROPOSED CONTOUR 0 o A. ROB N :r o C E � W. °r NOTE: T.HE LOCATION•OF ANY UNDERGROUND � V Y � j SEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON A A N0 10050 p V1ftk r. THIS PLAN IS APPROXIMATE ONLY AS DETERMINED �o�`��isT��� FROM RECORDS AND/OR VERBAL INFORMATION. THE CONTRACTOR IS RESPONSIBLE FOR THE yr '1.,1 VERIFICATION.OF THE EXISTING LOCATIONS IN THE FIELD. I TERE ENGINES R ISTER D LAND SURVEYOR LEVY Ek ELDREDGE ASSOCIATES,INC. CLIENT /Gl- PEOPOSED PLOT PLAN ENGINEERS- LANDSCAPE ARCHITECTS JOB NO. /•..226 -per PLANNERS - LAND SURVEYORS OR. BY: � IN 889 WEST MAIN STREET CHKD.BY: 34F�/QsT,48LE PIZ9 ' CENTERVILLE, MA. 02632 SHEET. L_OF? SCALE: DATE:_13y116 hF7 f a' /VOTE IC 7AMAC OR - ' 20 FT. M/N: G-A=ACK/�VG PIT .4RE /yOR..e WA/V /2 �SE401'V lD Imo' . Ik 4.'oiq /;4ADF, A 24"A0/AME7'Ze Co VCRET� COVER ScafEoti[ 40 SNA 1-4 &,F AgA?0414a IT 7"O <; TTAZ> CO .RL� M!/V. PITCH h►ERVY CAS7''/UPON COi/�� SH/,�GI- l3E USED IF /,V 27R/VE-WA Y- r. 21 W/lv. CD/VC&AEr7 A A p- CUY'ER - C3Jt E /V SAN® A CL A jr fD EVEL _ fi: �tJ[rCs�` uQU ,L,l r- 2� -AYE 3 40 fylfR►.P/T"CN" �+ ®� r t� DtST, s r I e • o . • •r • p o4 WASHaO SPONE . o ay • t ® • s o . • • , s s D" A • EFFECT/VE $ +y 3/1 a- �2p • • + ♦ • D€P?X • • • • • pa WASNED STONE -- //.3.D �/�� ►�s • • . • • s e • • o e p PRECASY SE.eA4'GLr. INY�� �L�dTAA/®N� /l3 7�/.a ff `oe • • • •. s . . e • e `o P/T DRU/V. . Sri c,9 )7V- 9o, "<4rp/a /NYZAT AT &VIL®lnsG 9 3 a ter. 6 Fp . y Q r /Z F/ Difar/. C(s��r•�uL.aTlo�v> IJV4R7 .�'P7�fC T�4fVaC ai a8/T��T SEPTIC 7�'A/V f•C FT. /WL,7'AISTR140VT/ON BOX 9 ' AFT. SECT/ON OF GROuN® Hl�1TER TABLE Ta1sr,qf,&vria/v WX,_ W14 .��N✓�4G� ®0�'�I�A L. .5'Y'.S� / T d.�.•aCHllvCs P/T _ LFR 7'8411-ATIDIV . 45ACH11wa z.7 DRSIGN CRITERIA D/Nx-jvsION �JF/1+•9SEP of SE'DRooms DIMENSION PT. . GAROA6EDI SPOSAL UN/r o v SO/z- LO& 6W4 7'E57" TaTAL E577/wA-rED FLA6R/ 3 3 oG,4,L-1,0Av SOIL TEST A/ SO/L 7X'ST#2 AtUMVEAP QF 204cKlaa /7s- 4 A,—A-L�Y, DATE OF SO/L TEST 21/�1 Sf 5/4DA-5 42'ACNIM6 -An'ZR PIT . 5SQ. PT 0 �-3 .Lcoq" RES'UA.77S AV.17-/V E ESSD BY T) 7E,A S CDAJZ,0 ; ®077ro 1 LzqCN/NG PAR pi SQ: F� .40F�VCOXA770W RAT45,0/ L 2- ^11AIII1VCH 7-07,4/- l.-ACHI/VG AREA 2-62 SQ. FT. ` F Mess _ iy ED/v/y v/L ,5 7 Z)C ® P A li 1, q�y� - SFrr1D ROAD LEVY Flo 10050_Q �e LEVY & ELDREDGE ASSOCIATES. INC. FG/SMAIN STREET CENTERVILLE,MASSACHUSETTS 02632 FFss .N L r.wr NO GROUND kV,47ER E/VCOIJ/1/TLsREO G L/ENT: /f./. / DATE GRO UNlD Pt/-47---,4e AT E L.E1/. JOS ND.�71/2 2-- S.Aiz F