HomeMy WebLinkAbout0326 TURTLEBACK ROAD - Health 326 Turtleback Road
Marstons Mills
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LOCATION jCrk K-4ZE SEWAGE N 27-921Z
VILLAGE !'l!rt�ly//7��$ ASSESSOR'S MAP&LOT D6�'Dy/INSTALLER'S NAME&PHONE NO. R,/� 6%9, �_FiX
SEP
TIC TANK CAPACITY 4SOD
LEACHING PACILITY:(type) /000 elr (size) &0 666
NO.OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER- /L.
BUILDER OR OWNER, (LI;!gf
DATE PERMIT ISSUED:_
DATE COtIPL1ANCE ISSUED
VARIANCE GRANTED: Yes No L-- '
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�✓a TOWN OF BARNSTABLE
LOCATION Zdi SEWAGE # 97` 9;Zz
VILLAGE ASSESSOR'S MAP 6t LOT
INSTALLER'S NAME & PHONE NO. 6�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) /600 Pf'r (size)
NO. OF BEDROOMS_3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER &E;M �s
DATE PERMIT ISSUED: ( - - ce
-DATE COMPLIANCE ISSUED: / -
VARIANCE GRANTED: Yes No �'
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............oF....... Q-cb► ...................
Z Appliration for Dispoiial Works Tonstrurtion ramit
Application is hereby,made for a Permit to Construct ( /or Repair ( ) an Individual Sewage Disposal
System at
............ .... L P� G�......�' .............................................. -•---•------..... -a .. ----
... __
" ----Location- ress
---pp--- --i--
��A f� ......µ
W Owner Address
a ................................................... ........
Installer Address
Type of Building Size Lot.. ✓.�'..v t....Sq. feet
-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—T e of Building g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
_ Other fixtures --------------------•----------•---•----......--------.....------------.
W Design Flow............��.2........................gallons per person per day. Total daily flow-----------3�-2 p....._.__.__ ......gallons.
WSeptic Tank—Liquid capacityl!2k�.;.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Pit No.,_..__.�-------
SeepageDiameter-_: .`.-_a".. Depth below inlet..'- �`?__. Total leaching area.P g �� "�.._.s .G4'i�
z Other Distribution box (� Dosin tank
'-' Percolation Test Results Performed by.n! W.........
Test Pit No. 1.......&.....minutes per inch Depth of Test Pit.....1'4:'....... Depth to ground water...I PLJC-•--.
(z., Test Pit No. 2......'4:.....minutes per inch Depth of Test Pit-----i!L�__._.. Depth to ground water____._..'..............
I x ••..--------------�------ --P-------5�..-.-----�._.?__r3._s___.o..._�____...r..••••...._.._;__._..................................................................
O #7 � Z. fZ --
Description of Soil1_.-----••- .-- -
c ------ Gold- �� _
w �L �,
x Qc�g `
r � ._: .s_. JcLt._-- -j2--G---•-U,
U Nature of Repairs or Alterations—Answer when applicable........................................................... .VAC�:...10...COA4-aSG
---------------------------•-------•----------•••----•-....----------•------------.....•-••--•-------------•----------------------------------------------------••••-•�-�d .....---••-•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi!L- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by bo lth.
Signe :__. ... -
Application Approved By..... .................. •••-•.....-•-----------•-•----• --...... ...W . .
Date.
Application Disapproved for the following reasons:-------•-------•--------------------•------------------•--------------------------------------------------------
--------••----------••------•-------------------•-------•-----..............-----------------•--•-------...---•--....---------- -------------------------------------•-••------...-n.-----------•---
,. "' -------------- Issued.............
iy
,..'
No... .. � �'d.)� FEic .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApplirFation for Dispas al Works Tonstrurtiun rrmit"",
Application is hereby made for a Permit to Construct ( +1�or Repair ( ) an Individual ,Sewage Disposal
System at
. ..a..... -------------------- ...........................................-......................................................
q t Location-Address
t ...{�i 7c �� ..........<, �1:.'JN c4 I '�� >' E! �h i:` 1.4� i� a� l� ^1�=��•�i✓f�1�� ._
............ ......... ............................. ...... .a.......... P
W Owner Address
a ....... ....... .........
Installer Address
!i U Type of Building Size Lot.`2 f`.6 =_..Sq. feet
Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T
YPe of Buildin g --------•----•-•------------ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow............ ''....................._._gallons per person per day. Total daily flow............�� '._..........._.....gallons.
WSeptic Tank—Liquid capacity!k`�2'71.gallons Length................ Width................ Diameter........ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.................... Diameter.. :__'._.. >:__. Depth below inlet.-f._..... Total leaching area.!-'`':' -...sc��ft. 7.- 0
Z Other Distribution box ( ° Dosing tank ( )
Percolation Test Results Performed by.... "..................
. '?t:l?.. a '-` `.. �Date.....`.!fe'f! f k�.................
Test Pit No. I.....`f.e ..__.minutes per inch Depth of Test Pit-----t.2__......... Depth to groundwater__
fl, Test Pit No. 2.......tea.....minutes per inch Depth of Test Pit..... . ...... Depth to ground water........................
a' ......................
••..................... -----.----- -------------------•----
O Descri Description of Soil') .. � � rl,� ."z;..g� .. �w r�, x ,�.` r ;.........
U � P :r> ---••-.•--_._ 1 ......----•------•...... :............ . ° -� 'fit . + ! --
W € l yr �. t 4 ( j� 0 9 4 ? F_... 4.^ IG:aI • _ ? f �:Fi al i :
......................... .______.. ......._.._. .c....._.__..__.... ._...._. .... 9. .._....�.............. 1.
U Nature of Repairs or Alterations—Answer when applicable...................... .. ................................ � _o.f ...a. F
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by bo f ealth.
Signe ... - ----------
s.,_Application Approved BY--- t f-E'-°�l _./ .�..�_�..... . ..................................... �Z--------....
� / a
Date
Application Disapproved for the following reasons:................................................................................................................
---•.........................................•-•--~--•--------•....--•----•----.._.......-----------•-•...._...--•-•-----------••.......---•--•--••--•-----•---•-•--.._......--Da......----------
te
PermitNo.-- - .... -------•-------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F...........................oF...............'................. ..... ........m:............................
Tntifiratr of f omplinnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-•-•--------------•----•----•-_•. ..------•---...-----......---------------•-•---------•---- --------------------...----------......---------------------.......--•.....------.....---------
nstall
at.. Fp/ 1 / ----•P Y---.--!!!.°.�� ...................................................
has been installed in accordance with the provisions of TITLE,-5 T,j� State Sanitary Code d s� ' ed in the
application for Disposal Works Construction Permit No......
�S_(7!.�._._. dated---------- � �
+�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
D OF
/ D... )/V OFRBIf.I�..AL �J ---•••••-•--...._.... s
/� tom..... )
NO.... .�l...0 1. FEE... ./
Dispo al Vorkv Toasts rtion rrnait
Permissioni hereby anted..............................................................................................................................................
to Construct ( ) or Repair_.( ) an I d,ividual Sewage p sal S}' tem / r,
as shown on the application for Disposal Works Construction Permit No.0.._.._ ated.....
�... . . ------------------
---------------------------------------
-
D /
DATE................ Boa�-----•------ ----/------�•-•-------------•--•---••-----.. of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
s Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M •'` 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is Marstons Mills MA 02648 June 10 2013
required for every ,
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your 1 �
cursor-do not David D. Coughanowr, IRS `fig
use the return Name of Inspector
key.
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
P-S
June 10, 2013
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
Removal of garbage grinder is recommended
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Clamber 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 .-equired 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
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:
D System Failure Criteria Applicable to All Systems:
Y pp Y
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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10 2013
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M a 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is Marstons Mills MA 02648 June 10 2013
required for 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 ears usage 115 gpd
9 ( Y 9 (gpd))
Detail:
2011, 2012
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M s 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
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:
24+ years. Certificate of Compliance for new system issued 12/9/1988 (on as built card -permit 87-
822 at Health Dept).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
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.):
2 sewer lines appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 2
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:
10.5 x 5 x 6-1500 gallon
Sludge depth: 8 in
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
page. Cityrrown 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 26 in
Scum thickness 1 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time, but maintenance pumping is recommended within 1 year and every
2-4 years thereafter. Tank and tees appear structurally sound and functioning as intended. No
evidence of leakage in or out was observed.
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
;M 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is Marstons Mills MA 02648 June 10 2013
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M a 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.) .
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at 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.):
D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was
observed. Some solids in sump.
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.):
i
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
r -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is Marstons Mills MA 02648 June 10 2013
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to
contain 10 inches of effluent in a 1000 gallon precast leaching pit. No staining at cover interface or
into riser was observed
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
9 ❑ ❑
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
326 Turtleback Road
M
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title Offs alp Inspection Forte
Subsurface.Sewage Disposa[Syste.rn Form,-Not for Voluntary-Assessments.
326 Turtleback Road
Property Address;
Karen Olsen
Owner
Owner's Name
information is
required for every Marstons Mills. MA 02648: June 10, 201-3
page. Cityrrown; State ZiP Code Date of Inspection.
D. System Information (cone.)
Sketch'Of Sewage Disposal.Systm -,;of the: mne we ; cluding-ties to
at-least.-two permanent reference-landmarks or benchmarks. Locate alGwells 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;
:2
vt�lr
0 SEPT t ¢
W _
LL SAC 0 4
15ins•31.1'3, Titles Official lnspociian Form;Subsurface Sewago'Disposal System•'Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 10, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high round water: 20+
p g g 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: 10/31/1988
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:
Town of Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 0.8 feet above
the bottom of a witnessed test pit in which no water or groundwater mottling was indicated. Town of
Barnstable GIS Department records indicate that the property is over 20 feet above groundwater
table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Karen Olsen
Owner Owner's Name
information is
required for eve Marstons Mills MA 02648 June 10, 2013
G 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
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
_.. J.) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 10-27-2020
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:out
A. Inspector Information (5/4 /15 pp y
forms
fillip out forms
on the computer, Daniel Hawkins
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return key. Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
raa (508)477-0653 S114324
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Dan Hawkins ;'Fora 2ozo 0.2913.7sszaavo• 10-27-2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.712 612 01 8 Title 5 Otfidal Inspection Form:Subsurface Sewage Disposal System+Page 1 of 18
r
Commonwealth of Massachusetts
--- 1119 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V 326 Turtleback Road
V�
Property Address
Michael Kelley
Owner Owner's Name
information is
Marstons Mills Ma 02648 - -
required for every 10 27 2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑■ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in workingorder at the time of inspection. Dwelling has a garbage grinder
P 9 9 9
but system is not designed for it. It is recommended that the grinder be removed to prolong
life of SAS.
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.
I
❑ 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
rn -_ Ti Sewage tle 5Official Inspection Form
p ys aForm Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7126/2018 Title 5-0tricial Inspection Form:Subsurface Sevrage Disposal System•Page 3 of 16
Commonwealth of Massachusetts
---, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
326 Turtleback
I
� c Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cone.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ El clogged
of sewage into facility or system component due to overloaded or
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.doca rev:7/26120:18 Title 5'official Inspection Form:Subsurface Sewage Disposal System:Page 4'of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
........ 1n) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 10-27-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/z day flow
❑ a Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ [D 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.
❑ l 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.
❑ El 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.
❑ 0 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
t5irisp.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
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
R ❑ Has the system received normal flows in the previous two week period?
O Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ R Was the facility or dwelling inspected for signs of sewage back up?
l ❑ Was the site inspected for signs of break out?
E ❑ Were all system components,excluding the SAS, located on site?
0 ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ 0 Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
0 ❑ +Existing information. For example, a plan at the Board of Health.
El 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'712 6120 1 8 Tithe 5 Official Inspecdonform Subsurface Sewage Disposal Systema Page 6 of 18
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
.) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
LJajr/
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 549/GPD
Description:
3
Number of current residents:
Does residence have a garbage grinder? 0 Yes ❑ No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes [E No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
2019- 76,000gallons 2018- 57,000gallons
Sump pump? ❑ Yes X No
Last date of occupancy: currentDate
t5insp.doc•rev:7/26/2018 Title 5 Official Inspection Fohn;Subsuffece sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
+� ,P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow.(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- last pumped 2019
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.7126/2018 Title 5.Oificial Inspection Form:Subsurface Sewage Disposal System.Page 8 of 18
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
-- __ M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.�; 326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
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:
1987 per plans
Were sewage odors detected when arriving at the site? ❑ Yes W No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron X 40 PVC ❑other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments(on condition of joints,venting,evidence of leakage,etc.):
15insp.doc-rev.7/26/2018 Titles Official Inspection Form::Subsuftce Sewage Disposal System-Page 9 of 18
Commonwealth of Massachu
setts
-I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
)•
1'
Depth below grade: feet
Material of construction:
W concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 500gallons
6"
Sludge depth:
30"
Distance from top of sludge to bottom of outlet tee or baffle
4"
Scum thickness
6r�
Distance from top of scum to top of outlet tee or baffle
13If
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5inspAoc+rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systefn•Page 10 of 18
1 Commonwealth of Massachusetts
...........
Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade: NA
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 Fono:Subsurface SevAge Disposal System-Page 11 of,18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0"
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev:712612018 Title 5 Official Inspection Form:Sobsurtace Sege Disposal Systein..Page 12 of 18
Commonwealth of Massachusetts
s =: Title 5 Official Inspection Form
:
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
...... ......, � 326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
El leaching pits number: (1) 6'x6' pit
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official inspection Form;Subsurface Sewage Disposal System•Page 13 of18
Commonwealth of Massachusetts
�- -- -- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V
326 Turtleback Road
V
Property Address
Michael Kelley
Owner
Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. Cityrrown + State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
The
SAS was In working order at the time of inspection. Pit was approximately
1/2
full when viewed.
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5insp.doe•rev.7/2 612 0 1 8 Title 5 Official Inspection Farm:Subsurface'Sewage Disposal System Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
= pi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
J 326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA --
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc reVi 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewege Disposal System-Page 15 of.18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
St
page. City/Town ate 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:
F■ hand-sketch in.the area below
❑ drawing attached separately
# IT
y. f
`s
{
A;,C
Y .ire.
t5insp.doe•rev.7/2612018 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
326 Turtleback Road
Property Address
Michael Kelley
Owner Owner's Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
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: NoGW@12'feet
Please indicate all methods used to determine the high ground water elevation:
[] Obtained from system design plans on record
12-14-1987
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15insp.doc•rev:7/2612018 Titte 5 Official Inspection Form:Subsurface Sews a Disp
osal possl Systerrr•Page 17 of 18
Commonwealth of Massachusetts
- -- --, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
326 Turtleback Road
Property Address
Michael Kelley
Owner Owners Name
information is Marstons Mills Ma 02648 10-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
X A. Inspector Information:Complete all fields in this section.
F0 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
R 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.2/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal 3ystern•Paget 16 of 18
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