HomeMy WebLinkAbout0016 WEBSTER ROAD - Health (2) 16 WEBSTER ROAD
MARSTONS MILLS
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THE MONW H OF MA SACHUSETTS •ex1f�,
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!-'F;>4-_W rr" BOAR® OF HEALTH ®or WH "I
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G� TOWN OF BARNSTABLE �
Appliration for Uiipuaal MurkB Tumi nr 4
Application is hereby made for a Permit to Construct ( ) or Repair (k_)elan Individual Sewage Disposal
System at:
---:..._... ... � v�b��................_. �....,.. .�c i ._........ - .............
Location- ess or Lot No.
.................. ..... _. ti`E. .................... ----•------ --...................... .........----•--------------- ....---_-_•.
Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.:............. _.___Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
a' Other fixtures ................................. .
w Design Flow.:.... . .....................gallons per person per day. Total daily flow....... . .....................gallons.
WSeptic Tank 1 Liquid capacity� ..gallons Length........... Width.... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.................... Diameter......I ------- Depth below inlet....(......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground Water........................
914 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
a -----••-----•---•••-••---•--•----••-••--•••--•••••---------------------------------------•-.....-----•............--•••_....•--------•--------.._....--•-----
CDescription of Soil......................................................................................--------------------------------------------------------------------•------.-----
x
U -------------•--•-----•••-•---•••----•-------•-------•------------------------•----••----........_._.....--------------------•-----...--••--...-------•••----......---•---•-----•-•---•-----------•----.
w
------------------------------------------------------------••-•-------
U Nature of Repairs or Alterations—Answer when applicable...__=�5��l� � �� � V.l ..y f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com Tian e has be issu the b and of ealth.
Signed
------------
.........................-- -`----------- ----------------------- ----- ..N---- - 'CAPPlication Approved BY ... cute
Application Disapproved for the following reasons- ------------------------------------------------------ ........------------......................................................
-------------------------------------------------- q......--..............--.....----------- .. ........-----------................................................................................ -----------------------...........:..
PermitNo. ..-- s�d -------------------------- Issued ---------------------- ate--.........................[e......
Date 'I
I— J
L
F.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -tt"o cx
(G
3
1I, TOWN OF BARNSTABLE NJ�r j U
Aopfiration for 14oposal Murks CffonshvdindjJrrMi#
Application is hereby made for a Permit to Construct ( ) or Repair (�_Yan Individual Sewage Disposal
System at:
r. -LocationfAaa�ess or Lot No
-1-" - 5 vim.-,
Owner A
------------------------------ --- ------------------------- --
Installer Address
Type of Building Size Lot-----------___---_______Sq. feet
U Dwelling—No. of Bedrooms.__--S-----------------------------------Expansion Attic ( ) Garbage Grinder ( )
a
Pk Other—Type of Building .___________________________^No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfigures ------------------------------------------------------------------------------------------------------------------------------------------------
W Design Flow......... _________________________gallons per person per day. Total daily flow-.---- 5��--�'-------------------gallons.
WSeptic Tank 1-Liquid-capacity __gallons Length--- ----------- Width----�------- Diameter----------------Depth_-______..___.__
x Disposal Trench—No-----------------.---- Width--------------------Total Length--------------------Total leaching area-----------------sq. ft
Seepage Pit No-------I------------- Diameter------1-2------- Depth below inlet----C ------Total leaching area_-------__.—sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY------------------------------------------------------------------------- Date---------------------------------
a Test Pit No. I________________minutes per inch Depth of Test Pit------------------- Depth to ground water--------------------__-_
ri, Test Pit No. 2----------------minutes per inch Depth of Test Pit-.=._.____----.__-_ Depth to ground water_-____--.-__._-_._..-.-_
a -------------------------------------------------------------------------------------------- -- -- —— -----
0 Description of Soil--------------------------------------------------------------------------------------------------------------------------------------------------------
VW -------------------- --------------------------------------------------------------------- ---------------------------------------------------------
Nature of Repairs or Alterations-Answer when applicable-------------------------------
----------------- ------------- — — — -____ _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with r
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp has bee issu d_b_the Ward of health.
~ - �-
Signed-------------��---"'--------- `Z � � `7
Dm
Application Approved BY - ------------------------------------------------- - -c%
Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------
PermitNo. ------ ---------_ -�- Issued` ----------------------- -----------------------�--------------------------------------- f
THE COMMONWEALTH OF MASSACHUSETTS / } ell'
BOARD BOARD OF HEALTH
TOWN OF BAR��TNSTABLE � p� 11231
Olertifirate of THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by -- '-�'0 !`{n �� P �- -_------------------------------- - =- ------------------------------------------------
fuSraller - I - A I
at -7 -�'��`O`(N1gw`t-� C' - �`' FI/11A`—L V1rfl1�1` S
-----------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -------9.Z__-_ ----------- dated _-_______------_-__________________--__-__--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFAtTORY '
DATE--------------------------------------------------- ---- 1. / ` Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No---------------------
Disposal Vorks Tonofru#ion Errant
Permission is hereby meted----------- - ` ``1- - C -- ---------------------
to Construct ( ) or Repair ( c)-g Individual Sewage Disposal System, �/�
at No---------------------------------------------- --------12 N_�� W�c�w �- - �JU- '-e -- - 1' " '`Z`V
- -----_
Street
as shown on the application for Disposal Works Construction Permit No._� _ ___ Dated----------------------------_------.-
------------------------- -"--�------------------
-------
------ __—_—
�, Health
DATE------------------- Board of
c�� (� - =----------------------
FORM 36508 HOODS Q WARREN.INC..PUBUSHERS
*: Commonwealth of Massachusetts f a3- 03(a
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name /
page. Marstons Mills V MA 02648 December 21, 2020
City/rown 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. Inspector Information SI 4 1.50&
1. Inspector:
Nicholas Geneseo
Name of Inspector
Wind River Environmental
Company Name
46 Lizotte Drive Suite 1000
Company Address
Marlborough MA 01752
CityrFown State Zip Code
(973)830-6126 SI 13988
Telephone Number License Number
B. Certification
I certify that:1 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:
0 Passes
❑ Conditionally Passes
❑ Needs Further Evaluation by the Local Approving Authority
❑ Fails
December 21,2020
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
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.
t5ins.doc rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 1 of 18
i - -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
Cityrrown State Zip Code Date of Inspection
C. Inspection summary
Inspection Summary: Complete 1,2, 3,or 5 and all of 4 and 6.
1)System Passes:
Q 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:
The system is working properly at this time.The filter was cleaned and 1000 gallons were pumped from the tank
during the inspection.
2)System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be replaced
or repaired.The system, upon completion of the replacement or repair,as approved by the Board of
Health,will pass
Check the box for"yes","no"or"not determined"(Y,N,ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below)
t5ins.doc 9 rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System 9 Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
Cityrrown State Zip Code Date of Inspection
C. Inspection summary (cont.)
2)System Conditionally Passes(cont):
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system
will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect public health,safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
t5ins.doc rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21, 2020
City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface
water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well**.
Method used to determine distance:
**This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
c. Other:
4)System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ Q Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
❑ 13 Discharge or ponding of effluent to the surface of the ground or surface waters due to
an overloaded or dogged SAS or cesspool
t5ins.doc 9 rev.7/26/2018 True 5 Official Inspection Form:Subsurface S xage Disposal System 9 Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
Cityfrown State Zip Code Date of Inspection
C. Inspection summary (cont.)
4) System Failure Criteria Applicable to A11 Systems: (cont.)
Yes No
❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than t/2
day flow
❑ Q Required pumping more than 4 times in the last year NOT due to dogged or obstructed
pipe(s)_Number of times pumped._
❑ J❑ Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Q 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.]
❑ Q The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd.
❑ FJJ 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 C.4.
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 If of a public water supply well
t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 0 Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December21, 2020
Cityrrown 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"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 a/I inspections:
Yes No
Q ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ Q Were any of the system components pumped out in the previous two weeks?
Q ❑ Has the system received normal flows in the previous two week period?
❑ Q Have large volumes of water been introduced to the system recently or as part of this
inspection?
Q ❑ Were as built plans of the system obtained and examined?(if they were not available
note as N/A)
❑ Q Was the facility or dwelling inspected for signs of sewage back up?
Q ❑ Was the site inspected for signs of break out?
Q ❑ Were all system components,excluding the SAS,located on site?
Q ❑ 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?
Q ❑ 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:
Q ❑ Existing information. For example,a plan at the Board of Health_
❑ Q Determined in the field(f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
Cityfrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes Q No
Does residence have a water treatment unit? ❑ Yes 2 No
If yes,discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Q No
information in this report.)
Laundry system inspected? ❑ Yes Q No
Seasonal use? ❑ Yes Q No
Water meter readings,if available(last 2 years usage(gpd)): 79 GPD
Detail:
Usage:58,000 gallons 1730 days=79 GPD.Usage data provided by the Town of Barnstable.
Sump pump? ❑ Yes Q No
Last date of occupancy: Current
Date
t5ins.doc rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System e Page 7 of 18
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
City/rown State Zip Code Date of Inspection
D. System Information (cont.)
2. CommerciaMndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc_):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes,discharges to
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
General Information
3- Pumping Records:
Source of information: Wind River Environmental
Was system pumped as part of the inspection? Q Yes ❑ No
If yes,volume pumped: 1000
gallons
How was quantity pumped determined? Quantity measured by pump truck
Reason for pumping: Check structural integrity of the tank
t5ins.doc 9 rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 18
Work Order# 0217081934 Cust# 1997352 Customer Since:2 017 Tax: 6.2500 %
Job Comments Tech Comments
12/21/2020 AM T5 Inspection (No closing) SVC 1000 Galls; Cover(s) secured. Property clear by December 16 after lam
WRE has pump recs & Signed consent; Check your email for ticket #2020-951-5227. Recommended No Recommendation.
plans; Customer to be on site with Water Recs CC on file -RC System Operating Fine. Normal water level. Heavy top solids.
R/S due to storm ** Heavy bottom sludge. Both baffles are intact. Main line
Clogged. Filter is present and has been cleaned as needed.
Recommended Boost additive, CCLS additive. Cover(s) secured.
Pump every 2 years.
System Owner System Location
Elizabeth Callard Primary Home
16 Webster Road 16 Webster Road
Marstons Mills, MA 02648 Marstons Mills, MA 02648
(508) 415-1149 Thomas Callard (508) 681-8666
Service Date: MON 12/21/2020 07:15 AM Frequency: Call to Confirm:
Service Type: Standard Previous Service: 12/10/2020
Approx. Gals: 1000 CCLS:
Location Details:
Depth Below Grade: Custom Clean:
Cust Home: No Filter:
Township: Inspection/T5:
County: Barnstable Build Up:
Description Qty Unit Price Ext Price
Inspection Title 5 (not including pumping) 1.00 $ 395.0000 $ 395.00
Inspection (Labor/Exposure Fees)per hr. 0.00 $ 150.0000 $ 0.00
Inspection Title 5 BOH Fees 1.00 $ 25.0000 $ 25.00
Pumping 1000 1.00 $ 235.0000 $ 235.00
Environmental Compliance - Residential 1.00 $ 3.0000 $ 3.00
Fuel / Energy Recovery 1.00 $ 44.1000 $ 44.10
Subtotal: $ 702.10 We suggest these 3 keys steps to keep your system healthy:
Tax $ 0.00 • Regular servicing
• Use CCLS bacteria additive
Total $ 702.10 . Use a filter
Disposal Site: Disposal Volume: Payment Detail:
Waste Code : 0.0000
Visa
Sales Rep : NE_Repairs Installs CSR : Ryan Council Due on Receipt
Truck: Technician : Nicholas Geneseo On Site : 08:14 AM P 0 Number:
Tech Notes :
System Operating Fine. Normal water level. Moderate top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. Filter is present and has
been cleaned as needed. Cover(s) secured. Title 5 is a pass, the tank is at Customer not on site
operating level with both tees in place. Cleaned the filter and ran camera to
the leaching chambers . The chambers are empty with no signs of hydraulic x
failure at this time. Serviced 1000 gallons from the septic tank at the time
of tye inspection. Thank you NG. Recommended No Recommendation. *****CC Customer Signature
declined please call the office***
WINDRrVERD
ENVIRONMENTAL
Remit payment to 46 Lizotte Dr Suite 1000,Marlborough,MA 01752
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7M
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
❑ Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attach previous inspection records,if any)
❑ Innovative/Altemative technology_Attach a copy of the current operation and maintenance
contract(to be obtained from system owner)and a copy of latest inspection of the t/A system by
system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
Q Other(describe):
Septic Tank to Leaching Chambers
Approximate age of all components,date installed(if known)and source of information:
2001
Were sewage odors detected when arriving at the site? ❑ Yes Q No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron Q 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
The main line is dear and properly pitched.
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's(dame
page. Marstons Mills MA 02648 December 21,2020
City(rown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
Q 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 Q No
Dimensions: 8'x 5'x 4'
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle 29"
Scum thickness 2"
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 14"
How were dimensions determined? Tape Measure
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
The liquid level is normal and both tees are in place.The tank is watertight and appears to be in good condition.
The filter was cleaned and 1000 gallons were pumped from the tank during the inspection.Recommend
pumping the tank and cleaning the filter annually-
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System*Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage, etc_):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow.
gallons per day
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System 0 Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s 16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21, 2020
City(fown State zip Code Date of Inspection
D. System Information (cunt.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level:_ Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches,etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
N/A
t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Foffrr Subsurface Sewage Disposal System 9 Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
0 7
" 16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
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.):
*If pumps or alarms are not in working orders stem is a conditional ass.
P P 9 Y P
11. Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
[� leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
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 soil is dry sand.The chambers are empty and there is no high staining.There are no signs of breakout,
hydraulic failure or groundwater infiltration at this time.
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 0 Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's(dame
page. Marstons Mills MA 02648 December21,2020
Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
t5ins.doc rev.7262D18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Flame
page. Marstons Mills MA 02648 December 21,2020
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of
the boxes below:
Q hand-sketch in the area below
❑ drawing attached separately
If V
tie J-15
i
i
1
I
i
Or
t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
o
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Q Check Slope
Q Surface water
Q Check cellar
Q Shallow wells
Estimated depth to high ground water 9'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ obtained from system design plans on record
If checked,date of design plan reviewed:
Date
Q 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:
Dug a small hole on the property with a hand auger.The hole was 9'deep and there was no dampness.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc rev.7/26/2018 T(de 5 Official Inspection Form:Subsurface Sewage Disposal System 0 Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Webster Road
Property Address
Owner Elizabeth Callard
information is
required for every Owner's Name
page. Marstons Mills MA 02648 December 21,2020
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Q A. Inspection information: Complete all fields in this section.
Q B.Certification: Signed&Dated and 1,2,3,or 4 checked
Q C. Inspection Summary:
1, 2,3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
Q D.System Information:
For 8:Tight/Holding Tank-Pumping contract attached
For 15:Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 16:Explanation of estimated depth to high groundwater included
t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System q Page 18 of 18