HomeMy WebLinkAbout0028 TURTLEBACK ROAD - Health 28-Turtleback Road -
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Marstons Mills
—_ A = 047 082
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TOWN OF BA INSTABLE ✓
LOCATION 2k TV f fie ea c 4 /J SEWAGE # -2 002
VILLAGE A/-yb,z ►' , )tz ASSESSOR'S MAP & LOT 0��� 0
INSTALLER'S NAME&PHONE NO. S co C
SEPTIC TANK CAPACITY /,SUO
LEACHING FACILITY: (type) (2) S—oo Ga Ion C1 rjsize)
NO.OF BEDROOMS oZ
BUILDER OR OWNERS / I/V
PERMITDATE:� COMPLIANCE DATE:' t6,42
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist }
on,site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
\Furnished by
-- Firmn fi
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No.
,.Yd1 z0� v��u^P'�v�7jirr Fee V //
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i /z
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Z(pprtcation for �Dfgpogar *pgtem Congtruction Vertu
Application for a Permit to Construct(✓rRepair( )Upgrade( )Abandon( ) ElComplete System ElIndividual Components
Location Address or Lot No. 2 8 TO 41C16, 'CIC k19. Owner's jName,
/Address and Tel.No. 1s
Assessor's Map/Parcel Ll `7 (j� �'�`4Gl`� 2 � �U'�7 C Q �Gk R&
Installer's Name,Address,and Teel.No./ 0 Designer's Name,Address and Tel.No. >
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder WO)
Other Type of Building Xes. No.of Persons -Z_ Showers(Z--) Cafeteria( )
Other Fixtures
Design Flow &L� gallons per day. Calculated daily flow Z-2-0 gallons.
Plan Date 14Ue.-4 /3 ?00Z Number of sheets Revision Date 4RX1 l3 zeo7-
Title
Size of Septic Tank �41 �G Type of S.A.S. A/ q
Description of Soil iye-e!o'n S4.10 G —Z
Nature of Repairs or Alterations(Answer when applicable)'464Q zey __✓`Z. c
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 TitleA of the ftironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y Board of ealth.
Signed Date
Application Approved by Date 5717 U
Application Disapproved for the following reasons
Permit No. .:)U 0 Date Issued S 17 J I
���� \
No. U� � " r.� Fee
` Entered in computer: �.✓
THE COMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
-.01ppYication for �Diopoar *p$tem Construction 3permtt
Application for a Permit to Construct(4--TRepair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. ' �e5L�� Q� ` Owner's Name,Address and Tel.No.
Assessor's Map/Parcel L-1 `'� ��
Installer's Name,Address,and Tel.No./ Designer's Name,Address and Tel.No. J
I calf -e Yc-4Y y (n Su1.14 4T S
3 Z ,4,® AP.
Type of Building:
Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder(it/,
Other Type of Building /QCS. No.of Persons 'Z-. % Showers(L) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow Z 2-0 gallons.
Plan Date /_pei,l /3 Z14702 Number of sheets Z~ Revision Date 4Pdi/
Title }
Size of Septic Tank; (r4� zfL Type of S.A.S. Z � �A/ C ,4Jy�r,E'S
Description of Soil JA?e_®/b,-7
Nature of Repairs or Alterations(Answer when applicable) i(��J1/���C
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 l of the ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue t ' Board of ealth.
Signed ` Date
Application Approved by D /1 - Date 570 U }
Application Disapproved for the following reasons
Permit No. DU o — j Date Issued S 7 d.1
---------------------------------------
61j>f , A 5'', 07, N-� - THE COMMONWEALTH OF MASSACHUSETTS
J As r� �'' BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by
at '�U f'41 o bR(k re M�` has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.rt)_00 2_2 t/ dated .S1/ / Z
Installer Designer
The issuance f this jer4t shall not be construed as a guarantee that the syst will function as ,e �gned.
Date Inspector d9� !Ile -
�j_
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi5po5ar *pgtem (tongtruction Permit
Permission is hereby grante to Construct( )R,pair( )Upgrade( )Abandon( )
System located at �$ �tV' Y�v,�c t �,
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:Cons ctio ust be completed within three years of the date of this permit.,l
Date: ��� 7 � Approved by
r
t
TOWN OF BARNSTAB LE
LOCATION 2 k I v r iie ea ck rd SEWAGE # _ 00-2-
VILLAGE "I tl ASSESSOR'S MAP & LOT'-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /I SU0
LEACHING FACILITY: (type) ('.L, ,-Asizef la ,k zj°
NO. OF BEDROOMS oL
I BUILDER OR OWNER E cJ
W -V
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist .
ea site.Qr within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
' within 300 feet of leaching facility) Feet
Furnished by
aoR
&Agat
ql '
/5oa d 4l -(cI�,c �q�k
.��,,,���n 1l'v�l✓ y _ ��e 7_�rir j
Commonwealth of Massachusetts 0 1-t-4-0g
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name /
information is required for every Marstons Mills y Ma 02648 4/28/2021
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information Sly 15"0-
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
rab Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com, S14522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/28/2021
Inspector's Signatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............. / 28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 28 Turtleback Rd Marstons Mills is served by a Title V septic system
consisting of a 1500 gallon septic tank, distribution box and 2 precast leaching chambers. Although
the system was found to be in proper working condition at the time of inspection this report does not
guarantee future performance under similar or increased usage.
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 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
in Title 5 Official Inspection Form
Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/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 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ 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:
® ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
r
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
28 Turtleback Rd
L
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
Description:
Number of current residents: 2
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�n
� 28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityfrown State Zip Code Date of Inspection
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:
system installed 5/31/2002
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints in good condition, no leakage, vented through roof.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e � 28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallons
Sludge depth: 5
Distance from top of sludge to bottom of outlet tee or baffle
3'
211
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
10"
How were dimensions determined? Opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turtleback Rd
v
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�e
- � 28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Bolding 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
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.):
Distribution box was video inspected and found in good condition with no rot. Water level was even
with outlet invert.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owners Name
information is required for every Marstons Mills Ma 02648- 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):.
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
P P 9 P Y 9
Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
28 Turtleback Rd
V
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching facility consists of 2 precast leaching chambers in a 25'x12'x2'trench. Chambers were
video inspected from d-box and found dry with a stain line approx. 6"from bottom.
12. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
(" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityfrown State Zip Code Date of Inspection
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
I
I
f
Commonwealth of Massachusetts
I� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� 28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. 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
_j
Al Z7
A2
aZ 33
A3 2S
33 37
A-V 3 Z
Ll i11t,
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
rm Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
b� 28 Turtleback Rd
Property Address
Julia Pursel
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 4/28/2021
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts �lf o y / - ogz
4 u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Tu ieback Road
Property Address
Kell
Owner Owner's Name
information is Marstons Mills Ma 02648 5/14/2015 4°'%
required for a:•
every page. CityfTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the p I O I I Q
computer,use 1. Inspector: S I # I (U1
only the tab key
to move your Scott Campbell
cursor-do not Name of Inspector
use the return
key. Cardinal Construction
Company Name
32 Ridge Road
Company Address
Cotuit Ma 02635
City/Town State Zip Code
508-420-1295 S1388
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ NeedjFurt r Evaluation by the Local Approving Authority
5/14/15
Ins ector's ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. �0 ,d v�s
00
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
I
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is Marstons Mills Ma 02648 5/14/2015 required for li
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified 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.
3. Other:
i
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Turlteback Road
Property Address
Kell
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
F W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
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
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Z013 d3►&xo qNki-5
11
IF
Sump pump? ❑. Yes ® No
Last date of occupancy: 2015
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM °' 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: 2015
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
5/31/2002 Compliance date
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
i
Commonwealth of Massachusetts
F W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 4
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
How were dimensions determined? sludge stick tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does need to be pumped at this time. both tees in place at time of inspection. Liquid level
proper working level. No evidence of leakage into or out of tank.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
u r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of Illiquid 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.):
box is set level. Equal distribution. No evidence of solids carryover or leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Clean dry soil. No ponding or hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
w L; Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
1 I
3ID° I
�13 N
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. City/Town State Zip Code Date oflnspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 13+
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: April 1, 2002Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Yankee Survey Consultants Design Plan Dated 4/1/2002
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Turlteback Road
Property Address
Kelly
Owner Owner's Name
information is required for Marstons Mills Ma 02648 5/14/2015
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
NOTE: EXISTING GAS & UTILITY LINE TO DIG-SAFE ALL UTILITIES PRIOR TO ANY CONSTRUCTION
BE RELOCATED FOR PROP. GARAGE.
• y RACE LANE '
, fo
s �'
o '4� BRUCE G�
CB I A.M 47/80 ' G. eCA -4wr LOCUS
c.a MURPHY ti No, TURTLEbBACK
O G _ No.749 RROA
� e8- '1, I _ S,q CISiEa P� ST Qy
�• �J Hs R� 00L
v "
G G Ip 24�0' LOCUS MAP
O 3 5' ROPOSED ,r t A.M 4 7/81 A.M 4 7/82
�C GE SLAB
Q
PLAN REF 30751 E SH I
-'` N ZONING: "RF"
°00'bIt 18,�C �.A�oAo FLOOD ZONE: "C"
l ASPHALT � \ARACE V 9Tf��'1j� sz� COMMUNITY PANEL#
DRIVEWAY A/QAGE CONVERTED b
?17 OFFICE do BATX ti 250001 0015 C
� ��0
L
DATED 8119185
2.0'J t_ 16. 0 CE5$P ; 0 VERLA Y DISTRICT "GP"
' TRIPOD -2 2 BED ROOM 2 BEDROOM MAXIMUM
12T 1 HOUSE 128 01 .8
0
Iz.8' 1 2.2 � xr 'b CESc�poOL � \
r
� TOP OF I FND=100. 0' 16. 0' b A. M 47182 PLOT PLAN
TP � _
o DECK, AREA 21, 370 SF OF LAND
y 0 VERLA Y DISTRICT "GP" LOCATED A T
y ''C 2 BEDROOM MAXIMUM g�
W _ _ ' -
12 0' G �, 106 28 TURTLEBACK ROAD
' I RELOCATED WATER � 12.5' ' o MARSTONS MILLS, MASS.
TO BE SLEEVED �\ CHIM.
' o PREPARED FOR
ED KELL
szz
APARIL 1, 2002
o,-90
A.M 47/87 .REV. APRIL 13, 2002
(1" = 20
YANKEE SURVEY CONSULTANTS
UNIT 1, 40B INDUSTRY ROAD
A.M 4 7/ MARSTO 83 P. 0. BOX 265
NS MILLS, MASS. 02648
NOTE: RELOCATED WATER TEL• 428-0055 FAX 420-5553
TO BE SLEEVED ✓# 53031 DCB
EL. =100'_
TOP OF FVUNDAT/ON
f� 20' MIN.
10' MIN. CONCRETE COVERS
4" SCHEDULE 40 P. V.C.
MIN. 6I7CH 1/8 PER FT. 2"LAYER OF
' B IIAK . . / CONCRETE COVER 96.5, 9 5,WASHED S719NE
98.0
4" CAST IRON PIPE 6 AlAX / 8 AIAX
POiRI� UA4 ERI FT~ Q RISER $ CLEAN o
Z,�, . 1 FLOW LINE 8�3' SAND EL=94.5
E , /
L 97 37 EXISTING lAllN 14" —E E 0 0 0 0 0 0 0 L
0 °°,°eF INVERT 6 SUMP �� '� o 0 0 0 0 0 a o o _ 91.65'
INVERT EL.= 96.5 INVERT INVERT o o ° -
EL._-9-6. 75 -- EL.= 94.50 EL.=94_25 4• 4
IN VERT
GALLONS DISTRIBUTION EL.
PROPOSED SEPTIC TANK BOX
7b BE TESTED
IF MORE THAN ONE OUTLET -25' X 12.8' TRENCH FORMATION �O
ZZ PLACE ON 6" STONE
SOIL ABSORPTION
PROFILE OF DOUBLE WASHED STONE SYSTEM (SAS)
SEWAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE OR VSGS PROBABLE WATER TABLE ELEV.= 85
NOT TO SCALE NO OBSERVED WATER TABLE (3101102) ELEV.=-85
t OBSERVATION HOLE I ELEV.=_98.0_
GENERAL NOTES PERCOLATION RATE <2 MIN./IN. 9 60"'
DEPTH UORIZ TEXTURE COLOR MOY"F OTHER
I) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.R
TITLE 5 AND THE TOWN OF -BARNSLIBLE---_ RULES AND 0-40" FILL
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. ,?"—44" , SANDY LOAM IOYR 3-2
2) ONE CO VER ON SEPTIC TANK. SHALL BE BROUGHT TO 0 VERLA Y DISTRICT "GP"
WITHIN 6" OF FINISHED GRADE, OTHERS PUTHIN 12" 44"-54" B LOAMY SAND .IOYR 4-3
3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF TWO BEDROOM MAXIMUM
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 54'-96" Cl MEDIUM SAND 10 YR 6-4 PERC
10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 96"-156 C2 FINE MEDIUM IOYR 6-3
4) ANY MASONARY UNITS USED 719 BRINC COVERS TO GRADE SHALL SAND
BE MORTERED IN PLACE. NO WATER ENCOUNTERED
5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. SOIL TEST P # = 10182
6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
IS 719 CALL 'DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS
PRIOR 719 COMMENCING WORK ON SITE. DATE OF. SOIL TEST 3101102 SOIL TEST DONE BY BRUCE C. MURPHY , RS.
7) CONTRAC719R IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. WITNESSED BY: DA VID STAN719N
8) PARCEL IS IN FLOOD ZONE-__C"_____. DESIGN CAL+C ULA TIONS:
9) LOT IS SHOWN ON ASSESSORS MAP _47_ AS PARCEL _82__.
10) CESSPOOLS 719 BE PUMPED AND FILLED. INSTALL TWO (2) ACME NUMBER OF BEDROOMS . 2.PROP . (3 DESIGN)
500 GALLON LEACHING CHAMBERS GARBAGE DISPOSAL . . . . . . . . . NO
11) RESERVE LEACHING WILL REQUIRE A TWO BEDROOM DEED RESTRICTION. WITH FOUR FEET OF DOUBLE, TOTAL ESTIMATED FLOW
WASHED STONE SIDES AND ENDS
} 25' X 12.8' ( 11Q--GAL/BR/DAY x _3 _ BF,-) 330 -GA LIDAY
PROPOSED SEPTIC TANK CAPACITY 1500 GAL
FIVE FOOT STRIP—OUT AROUND S.A.S. SOIL CLASSIFICATION . . . . . . . . I
TO APPROX. DEPTH OF 54" INCHES DESIGN PERCOLATION RATE . . . . . < 2 MIN./IN.
NOTE• BOARD OF HEALTH TO INSPECT EFFLUENT LOADING RATE . . . . . . • 74 GALIDA Y/S.F.
SAS EXCAVATION PRIOR TO INSTALLATION. LEACHING CAPACITY (AREA X RATE) 347 GAL/DAY
TO INSURE NO POCKETS' ON TIGHT SAND. RESERVE LEACHING CAPACITY . . . 222 GAL/DAY
(25 X 12.8 X . 74)+(25 + 25 +12.8+12.8 X . 74 X 2)
RESERVE LEACHING = (20. 7 X 8.8 X . 74)+(20. 7 + 20. 7 +8.8+ 8.8 X . 74 X 2) SHEET 2 of 2 JOB NUMBER-_ 53031_______