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HomeMy WebLinkAbout0135 WALNUT STREET (M.MILLS) - Health 135 Walnut Street Marstons Mills. A = 149 — 078 --- r r No. 1 L� Fee_AZ5!;0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitatlon for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 4�6 ❑Complete System ❑Individual Components Location Address or Lot No.13� n0)—S-i7- Owner's NkUAaakame,Address and Tel.No. ?4 U a/6- 3 Assessor's Map/Parcel/�l/G� mAYs�S 'A"I ,M A- -7qp/ dui lle�. . A- O-o Installer's Name,Address,and Tel.No. spy-ya$-89 oZ(C Designer's Name,Address,and Tel.No. �/� �t-+,016C Coc�s��c.�v�®s,�r+c s?v. A `70� Abc�n�� 11 o Type of Building: Dwelling No.of Bedrooms f} Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Pit gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nat re of Repairs or Alterations(Answer when applicable) jol Ar 1"j— jy� Gf.�Ce L'Oo7/I��� � S O � +• Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental t to place the system in operation until a Certificate of Compliance has been issued by this Board of t . p gne Date Application Approved b . Date Application Disapprove Date for the following reasons Permit No. &14—i4 4-4 Date Issued I ZJ 14 I Zo 1 S No. h ^ Fee� ao L THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 9 ❑Complete System ❑Individual Components Location Address or Lot No. 3 S �hU�--�j}• Owner's Name,Address,and Tel.No. ?(P U-d/6- 3 3 37 Assessor's Map/Parcel/y�UoFs /k IGt r S 1z�r1s r�(�I (1 ( )" Q/40_coa -)yq/ kra ID1 a. oCo Installer's Name,Address,and Tel.No. 50<d-t(a!R-$9 a G Designer's Name,Address,and Tel.No. +2;artvly -tirc S?v• +'pox `�vl�l /�(�cs�t�=fort T ` "U;l s 4114 vas(/ Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /�� gpd Design flow provided AM gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) `)!161/- t! 2.5 j; />/!_nr_1,ke..1 _ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code-and-not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heah . %inQ � Date Application Approved by Date Application Disapproved Date for the following reasons Permit No.;gy _�-4 Date Issued 14 141 Zoo 167 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS.TO-�CERTIFY,,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(�y 13or L/p { ,,,S�l, at I�J`rf(1/ j»�. f 21le r,T7rA A NtP.a., �t,/j+ has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.� ( ' 1 t� dated 1) Installer I- UoV A-a I U c0r`� -(f �i G Y�,—L Designer #bedrooms Of Approved design flow /U19 gpd The issuance of this permi shall not be construed as a guarantee that the system will ctio designed. Date I i f Inspector !J w /I ,e t ----------- ----------------------------------------------------------------------------------------------- ----------- ��� ou No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3dermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon System located at f 3S(" A4,1_ NGl MM ` and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this perm• . Date /J I��(7.0/ Approved by . .�. <,. �i-:A. .j � tl.� SpL }' :�•RF �r�Nr"^��F� t.. Y ..rl �.�.a4.. ••n •— _t- � �„ m'+• � •_. r .sue, ��� ..y.w ��� .. .. T �'tl'� / ``,, �D. e." �..�?�� r.,}„R'w�,.�t.} ��,x �'•ly"7�. ;i� `Y� f`SY`� '"1 �•• rl.�.. � .P�' r r , ..�. •w+�.r �,«�4.:.r�'.. r �+`•. 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Sep do pt-l�i0fic Between t11ts MaxizrtumAdjastecl Gtputaciwatet l'ahleita tlac Sottomoi?1.eHchln l Ry t�lv�tc: 1 4 ► up ly Wa1!Wid meat! 1 a6wty..(11,0 :; �6 0x t att sites a withit%�Ot3 eQt of wachina fn �rer�e. Psi �p c����/et9atit1 ai d Lsad elntt iFa ttity If�triy wetlan xgs4, Svitlaisi,30 fc A .. . . , .� fo D �a l r . C LyS�� i � S she"` , i. J , � � L N � � ,� �� � ��, a_F- �s� A a�P �-G9.�b` a'�� C ,��73, ����-�� i TOWN OF BARNSTABLE v LOCATION AS rA/6��h� � SEWAGE # VILLAGE 1045b4lns /W014-; ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(iype) (size) NO. OF BEDROOMS &3PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No fV a,N)s1" I3y H0,-A£0WNpr?- Tj %Z1 -4*, K6. j Town of Barnstable Barnstable Regulatory Services Department AtAnnftft • fARNSfABiE, • O D Public Health Division 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7015 1520 0000 1971 7019 Novemberl0, 2015 Kenneth L. Marshall 135 Walnut Street Marstons Mills, MA ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system#2 of 2 located at 135 Walnut Street, Marstons Mills,MA, was last inspected on October 20 2015, by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system" Failed" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Single Cesspools automatically fail in the Town of Barnstable. You are ordered'to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. P ER OF TH BOARD OF HEALTH as McKean, R.S. CHO o� Agent of the Board of Health Q:\Letters Septic Inspection Failures or Future Evl\135 Walnut St MM 2°d system Nov2015 Parcel Detail Page 1 of 3 IH 109 —,?� fo Logged In As: Parcel Detail Monday, November 9 2015 Parcel Lookup Parcel Info Parcel ID;149-078 _— l Developer[LOT B""°'""" Lot Location 5335 WALNUT STREET(M.MILLS) l Pri Frontage 187 l Sec l Sec Road; Frontage Village I AM RSTONS MILLS Fire District 1C-0-MM Town sewer exists at this address[No ��� I Road index F1778 Asbuilt Septic Scan: Interactive � — t ,_' 149078_1 Map ,i K u Owner Info Owner VMARSHALL, K NNETH L Co-owner) Streetl 135 WALNUT ST f Street2 City MARSTONS MILLS —I State MA zip 02648 Country Land Info Acres 0.73 ( Use[Single Fam MDL-01 Zoning RF � —1 Nghbd 10105 Topography (Level l Road FPaved Utilities;Septic,Public Water Location l Construction Info Building 1 of 1 Year I1972 M Roof Gable%Hip l Ext Wood Shingle Built, Struct" Wall Living 27 Roo GIs f 1Asph/F /Cmp Ac None as Area Cover Type_ 6 y 4 �. � S� Pil WDK Style tCa e Codp wall 3 Int Bed Bedrooms a 12: j p Wall rY Rooms_� 16 Int A .� d� Bath f— .», Model rt esS 5entlal l Carpet �l 12 Full-0 Half Floor Rooms tI , UR5 FH5 Grade Average � Neat jElec Baseboard Total Rooms' Rooms �� easy ° 9As � Type Rooms �' BMT3 _ __ _ `6AR 1 Stories 11 1/2 Stories�-1 Fue Heat"Electric ation l Found- Mixed ( �.UnTx zi s l ` � 2 1,7' Gross i�35 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=9965 11/9/2015 Town of Barnstable snxnsresr.E, Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6,2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy, below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any-portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO 2 YEAR DEADLINE CRITERIA Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a'driveway due to H-10 components, etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHE R ❑ Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 1 /y -07 Commonwealth of Massachusetts D Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM ,. 135 Walnut St (System 2 of 2) Property Address }, y Mike McCarthy Owner Owner's Name information is rM 1 required for every Marstons Mills MA 02648 10-20-15 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. A. General Information 1. Inspector: , Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 ocal Approving Authority 10-20-15 Ins tor'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. �o �s t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection B..Certification (cont.) t Inspection Summary: Check A,B,C,D or E/always complete all of SectionPD 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): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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 ❑T 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official, I n' spection ,-Form Subsurface Sewage Disposal System Form!-Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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: 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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 ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments M 135 Walnut St (System 2 of 2) - Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town 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? ® a ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ' ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions:— Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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: 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 Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General information t Pumping Records: Source of information: Owner--3yrs ago Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped:- gallons How was quantity pumped determined? Reason for pumping: Maintenance 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 alnte ance 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form—Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 1972 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ® casl 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syst9m•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. Cityfrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate,on 'site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes.. ❑ No" Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): P Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 24" Depth of solids layer 12" Depth of scum layer 1" Dimensions of cesspool 6x6 Materials of construction Precast pit Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary`Assessments M 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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.): Precast pit was holding water at 24" below inlet invert with stain lines above inlet invert. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately e PA CO) 5" I p �&, q17 73 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M '�f 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is Marstons Mills MA 02648 10-20-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) j Site Exam: 7 F ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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. i 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: USGS and town maps show groundwater at 20'. 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 HR Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 2 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f ` Commonwealth of Massachusetts / P79 � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M '< 135 Walnut St (System 1 of 2) Property Address Mike McCarthy = Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered iri any way. Please see completeness checklist at the end of the form. A. General Information �r 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 s ❑ Needs Further EvaI the Local Approving Authority 10-20-15 In ector'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. /G 6 t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts ' W Title 5 Official ,Ins pactio n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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 ® 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be ' replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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): r ❑ 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 t5ins-3/13 Tile 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 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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: 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 El ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3113 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 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. Cityrrown 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. El ® 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 H W Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is Marstons Mills MA 02648 10-20-15 required for every page. City/Town 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? El Z 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�' 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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: 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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--3yrs ago , Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: . gallons How was quantity pumped determined? Reason for pumping: Maintenance 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): r' r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official= Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I . Approximate age of all components, date installed (if known) and source of information: 1972 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ® cast iron ❑ 40 PVC ® other(explain): Orangeburg Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): i Depth below grade: 8"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: 1000 gal Sludge depth: 12" t5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) . . I Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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.): a Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments M 135 Walnut St (System 1 of 2) - Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan):. Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑l Yes ❑ No" Alarms in working order:, ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts - • Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 1 of 2) , Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ 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.): Leach pit in good condition and holding 12" of water with stain lines at 16" below inlet invert. 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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 , 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts a W Title 5 Official Inspection form Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately VP -J�e �731 . t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam.- El Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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'viewed: / .. ;'11� 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: USGS and town maps show groundwater at 20'. r 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form I' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 135 Walnut St (System 1 of 2) Property Address Mike McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 10-20-15 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17