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Commonwealth of Massachusetts (P
- Title 5 Official Ins ection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,
42 Wheeler Road
Property Address
Arthur P.-Doherty
Owner Owners Name
information is
required for every:. Marstons Mills✓ MA 02648 June 11, 2017 ;;
page. Citylrown State Zip Code Date of Inspection-
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see.completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, / aV
use only the tab 1. Inspector:
key to move.your
cursor-do not David D. Flaherty.Jr_ IRS,REHS
use the return Name of Inspector
key,
Flaherty Environmental Services. .
Company Name
P.O..Box 81
Company Address
Yarmouth Port MA 02675
- City/Town State Zip Code.
508-362-1657 SI`#4713
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. 1 am a DEP approved system inspector pursuant to Section 15340 of.
- Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ 'Fails
❑ Needs Further Evaluation by the Local Approving Authority
June 12,`2017
Ins ors Sig "tur Date
The system inspector shall submit a'copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection: If the system is a shared system or.
has:a design flow.of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies'sent to.the buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of'use.
t5ins-3r1 3 Title 5 Official Inspection Form;,Subsurface Sewage..Disposal System-Page 1 of 17
�,o �S
f
Commonwealth of Massachusetts
Title 5 Official Inspection Forrn
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P. Doherty
Owner Owners Name
information is
required for every Marstons Mills MA 02648 June 11, 2017
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:
® 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
two systems servicing the dwelling
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. 1#"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 El N ❑ ND (Explain below):
t5ins•3/13
Title 5 Offic al Inspection Form Subsurface Sewage Disposal System•Page 2 Or 17
I -
\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P. Doherty
Owner Owner's Name
information is Marstons Mills MA,. 02648 June 11, 2017
required for every
page. CityfTown State Zip Code Gate of inspection
B. Certification (cont.)
El 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 s.ewaqe. 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):
brokempipe(s)°are replaced ❑ Y ❑ N ❑1ND-(Explain below):
❑ obstruction is removed ❑ Y . ❑ N ❑ ND(Explain below):
El distribution box is leveled or replaced ❑ Y. ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken orobstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health),,-
broken pipe(s)are replaced' ❑ Y 0 N. ❑ ND(Explain below)*-
El
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
15.30(1)(b)that the system is not functioning in a manner which will protect public"health,
safety and the`environment
El Cesspool orprivy.iswithin 50 feet of a surface water ,
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins-3113 Title 5Affidal Inspection Form:Subsurface Sewage oisposal system•Pao 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 42 Wheeler Road
Property Address._
Arthur P. Doherty.
Owner Owner's Name .
information is
required for every Marstons Mills MA 02648 June 11 2017
page. Cityfrown State Zip Code, Date,of lnspecItion
B. Certification (cont.j
Z. System will fail unless the Board of Health(and Public Water Supplier, if an
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 is6ptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
Theaystem 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.thani 100 feet but 50 feet or
more from a private water supply well**.
Method used to r dete mrne 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 pprn, 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 orcesspool
0 ® 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 Y day flow
t5ins•3N3 Title 5 Official Inspection Form:Subsurface Se a Di5 wag pwal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Bnspecti®n Fornn
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P.Doherty
Owner Owners Name
information is required for every Marstons Mills MA 02648` June 11 2017
page. Cityrrown State Zip Code Dated Inspection
B. Certification (cont)' -
Yes No
0 ® Required pumping snore than 4 times in:the last year MOT due to clogged or
obstructed pipe(s). Number.of times pumped:
El 19 Any portion of the SAS, cesspool or privy is below high,.ground water elevation.
aAny,portion of cesspool or privy is Within 100 feet of:a surface water supply or:
tributary to a surface water supply.
JZ Any portion.of a cesspool or:privy is within a Zone 1 of a public well.
EJ ® Any portion of a cesspool or privy is within 50 feet of a'private water supply well.
0. N. 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
s tem asses if the well water anal sis- erforme a a DEP
y p y, . � p . _ d t 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 10000 gpd to 15000 gpd.
For large systems, you must indicate either"yes`'or no to each of the following, in addition o the
questions in Section D.
Yes No
E-1 0 the system is within 400 feet of a surface drinking water supply'
❑ 0 the system is within'200 feet of a tributary to a surface drinking watersuppiy
o the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-IWRA)or a mapped Zone 11 of a public water,supply well
If you have answered"yes"to any question in Section E the system is considered a sign ificant: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 3H 3` TiUe 5 Official inspection Form:Subsurface Sewage Disposal System-Page 5:of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P. Doherty
Owner
Owner's
Name
information is .
required for every Marstons Mills MA 02648 June 11 2017 ;
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 foilowing:
Yes No
® ❑ Pumping information was provided by the owner,occupant, or Board of Health'
❑ IZ 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?
1. ❑ Was the site inspected for signs of breakout?
Were all system components, excluding the SAS,located on site?
® Ell. Were the septic tank manholes uncovered, opened, and the interior of the tank
:inspected for the condition of the baffles ortees, material of construction,
dimensions, depth of liquid, depth:of sludge and depth of.scum?:
0 Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?.
:The size and location of the Soil Absorption System(SAS)on the has
been determined based on:
1Z ❑ Existing information.For example, a plan at the Board of Health.:
0 Determined in the field (if any of-the failure criteria related o 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): 5 Number of:bedrooms(actual): 3
DESIGN flow based:on 31'O.CMR 1:5.203'(for example: 1`-10 gpd x#of bedrooms): 550,
t5ins 313 TiUe 5 Official,inspection Form:Subsurface sews9 a D'isppsal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official. In sp etion Form
Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
b 42 Wheeler Road
Property Address
Arthur P.Doherty
Owner Owner's Name M
information is
required for every Marstons Mills MA 02648 June 1;1, 2017
'page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
bedroom expansion count confirmed by Tom McKean, Barnstable Health Director on 1/25/2017 (see
attached)
Number of current residents:.
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 d `14.27 gpd; '15:
Detail:
II
Sump pump?
Yes ® No
Last date of occupancy: current.
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? El 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 s official inspect on Form:Subsurfees Sewage Qisposal System-Page 7 of 17
Commonwealth of Massachusetts
- Inspection
Title 5 Official.
- fie Form
Subsurface,Sewage Disposal System Forme-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P. Doherty
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 June 11, 2017
page. Cityrrown State Zip Code Date of Inspection
De System Information (cont.)
Last`date of occupancy/use: Date
Other(describe below): -
General Information
Pumping Records:
Source of information: three years ago
Was ystem pumped as part of the inspection?. ❑ Yes �. :No
If yes, volume pumped: gallons
How.was quantity.pumped;determined? 77
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
,Single cesspool
Overflow cesspool
Privy .
0 Shared system (yes or;no)(if yes, attach previous inspection.records, if any)
InnovativelAlteMative 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 l/A system by system operator under contract
El
Tight tank:Attach a copy of the.DEP approval.
Other(describe):
t5 ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of V
Commonwealth of Massachusetts
_ Title 5 CJfficiai Inspection Form
Subsurface Sewage Disposal System Form-Notfor Voluntary Assessments
42 Wheeler Road
' Property Address
.Arthur P. Doherty
Owner Owner's Name
information`i's
4 n
required for every
Marstons Mills MA June 11 2017
026 8
a e. City/Town State Zip Code Date of
pg
D. System Information (cont..)
Approximate age of all components, date installed (if known)and source of information:
July 1, 1985 for both systems
Were sewage odors detected when arriving at the site? ❑ Yes ®. No
li Building Sewer(locate on site
PIan :
t h)
Depth below grade: feet material of construction:
®cast iron Jo 40 PVC' other(explain):
Distance from private water supply well or suction line: '30(both)
feet_
Comments(on condition of joints, venting, evidence of leakage,etc:)
joints tight, venting through dwelling adequate, no evidence of leakage
Septic Tank(locate on site plan)
Depth below grade- 1.75'(both)
feet
Material of construction,
®concrete ❑.metal ❑fiberglass 0 polyethylene . 0 other(explain)
i r
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy,of certificate EJYes ❑ No
1000 dalloh both)
Dimensions:
Sludge depth: 3",(both}
t5ins•3113 We 5 official inspection Form:Subsurface Sewage.Disposal Syslem•,Page 9 of 17
I -
Commonwealth of Massachusetts
Title 5 Off1 1 c al 011S
eCtr n
Q Fora
Subsurface Sewage Disposals System Form-Not;for Voluntary Assessments
'< 42 Wheeler Road
Property ertY'Address
P
Arthur P.'Doherty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 June 11, 2017
.
page;, Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top ofzludge to bottom of outlet tee or baffle 31"Sboth)
Scum thickness 1" both
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14
How were dimensions determined? dip`stick,aape 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.):
maintenance pumping should be every two to three years, inlet&outlet tees good, tank seems
structurally sound, liquid level appropriate, nor evidence of leakage
Grease Trap(locate on site plan):
Depth;belovv grade: feet
Material of construction:
❑Concrete ❑ metal fiberglass pol eth lene
y y 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 orbafFle
Date of last pumping:
Date
(Sins•3l13 Title 5 Of vial Inspection Form:Subsurface Sewage Disposal System'+Page io of i7
s
Commonwealth of Massachusetts
Title 5 Official Imp icon f term
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 42 Wheeler Road
I Property Address
A dr ss .oe
P
Arthur P. Doher
ty-
Owner Owner's Name
information is
required for 02648every :Marstons-Mills : MA June,11, 2017
page. CityrFown 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(explan):
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(re
9ulre d). Is.copy attached
�❑�.Y es. No`
[sins•3113 Title 5:OfFidat inspection Forn Subsurface Sewage Disposal System Page 11 of 17
�. Commonwealth of Massachusetts
Title 5 Official Ins ection Form
Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments
42Wheeler Road
Property Address
Arthur P; Doherty
Owner . Owner's Name
information i e required for every
Marstons Mills MA 02648 June 11, 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site.plan):
Depth of liquid level:above outlet invert 0"(both)7;
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_):
both dboxes seems level,'both had Very minor solids carryover, both.had no evidence of leakage
Pump Chamber(locate onsite 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.
I UFM
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
tsins•3113 Title 5 Once!Inspection Form Sutuurface Sewage Disposal System Page 12 of 17
Commonwealth of:Massachusetts
Title 5fficia Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P. Doherty
Owner Owner's Name .
information is :required for every Marstons Mills MA ' 02648 June.11, 2017
-i rT wn State. Zip Code Date of ins ection
C o P
a e. tY
P
P9
D. System Information (cont.)
Type i
2
leaching-pits number: �( )
El 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:):
(1)6'x 6'precast leachpit with 2`:stone.for both systems(2 total), both had no Visible'stain line, both
had no liquid in pits soils sandy'and gravelly, no signs of hydraulic failure or breakout for both,
vegetation typical(lawn)
Cesspools(cesspool must be pumped as part.of inspection)(locate on site plan):
Number and.configuration
Depth—top of liquid to in,. invert.
Depth of solids layer
Depth of scum layer
Dimensionsof cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes... ❑ No
t5ins•3113, Titl95 OHicial hspectian FamSubsurraw Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage:Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P. Doherty
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 June 1,1, 20.17
page. GityfTown 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,):
}
4
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.):
F_
l5ins 3113 Title 5 Offiaal Inspection Form.Subsurface Sewage Di g sposat System•Page 14 of 17
Commonwealth of Massachusetts
Title OfficialInspection Forr�t
Subsurface Sewage Disposal System Form_-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Arthur P. Doherty;
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 June 11, 2017
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
a c
east twro permanent referen e Iaodmarks or benchmarks. Locate'allllsw wethin 100 feet'Locate
t l :
where public water supply enters the building. Check one of the boxes below.
® hand-sketch in the area below
❑ ;drawing attached separately
J
f�l �
`,
1 Z
C,c ' LE
b
r
c�L 3
I.
� f
C
f .
cJ ^'' �f I S
t5ins•.3113 - The 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
w 42 Wheeler Road'
Property Address
Arthur P. Doherty'
Owner Owner's Name
information is
required for every Marstons Mills MA' 02648 June 11, 2017
page. City/Town State Zip Code;. Date of Inspection
D. System information (coat.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
>40
feet
Please indicate all methods used,to determine the high ground water elevation`:
❑ Obtained from system'design:plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAs)
❑ Checked with local Board of Health:-explain.
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe:how you establishetl`the high ground water elevation:
Barnstable's;1992 Groundwater Contours Map shows estimated groundwater to be between`40'and
45' below grade.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3113 TiNe 5 Baal Inspection Form;Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 4fficia . Inspection Form
s Subsurface Sewage Disposal System Form,-.Not for Voluntary.Assessmonts
r� r
Road 42Wheea l R d
Property.Address
Arthur P. Doherty.
Owner Owner's Name
information is MarstOns Mills MA 02648 June 11, 2017
required for every
page: C1tyrrown' - 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—Estimatedi depth to high groundwater
® Sketch of Sewage Disposal,System either drawn on page 15 or attached in separate filer
i5ins•3113 Title 5 Official Inspection Farm Subsurface.Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts /d
076
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is
required for every Marstons Mills ✓ MA 02648 April 1, 2016
page. City/Town State Zip Code Date of Inspection
a
Inspection results must be submitted on this form. Inspection forms may not be altered in
way. Please see completeness checklist at the end of the form.
h�
Important:When A. General Information
filling out forms
on the computer, ///5,v?.
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Flaherty Jr., IRS, REHS
use the return key. Name of Inspector .
Flaherty Environmental Services
Company Name
P.O. Box 81
Company Address
Yarmouth Port MA 02675
City/Town State Zip Code
508-362-1657 SI#4713
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Z'j I -
Aril 2, 2016
I ture spector's Signal Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
4
Dv4-' VS
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 1, 2016
required for every p
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
two systems servicing the dwelling
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
42 Wheeler Road
Property Address
Herbert C. &Gail M.Wells
Owner Owner's Name
information is required for every Marstons Mills MA 02648 Aril 1 2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑. N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Forth: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
42 Wheeler Road
Property Address
Herbert C. &Gail M.Wells
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 1, 2016
required for every p
page. Cityrrown 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
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-3/13 Title 5 Official Inspection Forth: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
42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner owner's Name
information is Marstons Mills MA 02648 Aril 1, 2016
required for every p
page. CityTrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Herbert C. &Gail M.Wells
Owner Owner's Name
information is Marstons Mills MA 02648 April 1 2016
required for every P ,
page. CityrFown 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? p
® ❑ 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
�M 42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 1, 2016
required for every p
page. Cityrrown 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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d '14: 27 gpd; '15:
9 ( Y 9 (gpd)): 15 gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2016
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
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 . Aril 1, 2016
required for every p
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
I
General Information
Pumping Records:
Source of information: owner's agent, probaly three years ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 April 1 2016
required for every p ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
July 1, 1985 for both systems
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5(both)
feet
Material of construction:
® cast iron ®40 PVC ❑ other(explain):
I
Distance from private water supply well or suction line: >30 (both)feet i
Comments(on condition of joints, venting, evidence of leakage, etc.):
joints tight, venting through dwelling adequate, no evidence of leakage
Septic Tank(locate on site plan):
Depth below grade: 1.75 (both)
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 gallon (both)
Sludge depth: 3"(both)
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sew
age wage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 42 Wheeler Road
Property Address
Herbert C. &Gail M.Wells
Owner Owner's Name
information is Marstons Mills MA 02648 April 1, 2016
required for every p
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 31"(both)
Scum thickness 1" (both)
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? dip stick, tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
maintenance pumping should be every two to three years, inlet&outlet tees good, tank seems
structurally sound, liquid level appropriate, no evidence 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 scum of to to of outlet tee or baffle
P
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 April 1, 2016
required for every p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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
42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 1 2016
required for every April ,
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"(both)
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.):
both dboxes seems level, both had very minor solids carryover, both had no evidence of leakage
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
M W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Herbert C. &Gail M.Wells
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 1 2016
required for every p ,
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (2)
❑ 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.):
(1)6'x 6' precast leach pit with 2' stone for both systems (2 total), both had no visible stain line, both
had no liquid in pits, soils sandy and gravelly, no signs of hydraulic failure or breakout for both,
vegetation typical (lawn)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 42 Wheeler Road
Property Address
Herbert C. & Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 April 1 required for every p �il , 2016
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 1, 2016
required for every P
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
Az -Yz
z� Ll4
C S- qz � -
D� � s �
V ,� f
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
w 42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 April 1, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >40feet
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
i
❑ 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:
Barnstable's 1992 Groundwater Contours Map shows estimated groundwater to be between 40'and
45' below grade.
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
I
Commonwealth of Massachusetts
' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Wheeler Road
Property Address
Herbert C. &Gail M. Wells
Owner Owner's Name
information is Marstons Mills MA 02648 April 1, 2016
required for every p
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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a F CERTIFItO PLOT PLAN
ROBERT
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sCALE. f - DATE
` a ,j� G� Ndf+llt ' JN I wz 1 CERI�LIY THAT THE �a - C-1.I NT.- 3H4'kA'W ON TIM33 PLAN is LoGl4Y D
E61.14TER1 R�1ISTERC4D: 3
CIVIL �,AIVb '0 NQ" - ON Tads 14#iDUND A INDICATE-0 AN
�N ICI R UR1�'Y.R 1 .NY► A-� 1l.
0.614F iINUS TO THE ZONING LAWS
_ ... - - - #F' BAPl14STthI3LiE, MASS
.' 71.2 MAIN S T R E E,r
• HYANRIS. M AS S. SMEEIF air/ UP UFA- I.Aelb qI)pwiwrarnA
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L 0 C TION SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
R U I L D E R OR 0W N-FAR _
DATE PERMIT ISSUED q-f- � J
DATE COMPLIANCE ISSUED
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No..!�... ®.�. Fizs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............ ..................O F...............I............
............
Appliration for Uh4posFal Works (foustrnrtiun Vamit
Application is hereby made for a Permit to Construct (V'*)*l or Repair ( ) an Individual Sewage Disposal
System at
..._..I A. ...H�.e`� Z?N� �`? e• ..................................... .......
Location-Add ess or Lot No.
Z.J7naa .�� !: ...
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Ogwner
•--�fL[��"'- "-"'•"--.... JLrC/.G .......................................... L`'✓-!hl .S�e! /../C.' r7C. ..__...--•----•--.....-----...._..__.
Installer Address
d Type of Building Size Lotlim—i%.........Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (Y)
Other—Type T e of Building No. of ersons____________________________ Showers
(� YP g ------•--------------------• P ( ) — Cafeteria ( )
Q' scp/fj4,.; Other fixtur
w Design Flow.... ._if 3_T.�-. q.�,4- allons per person per day. Total daily flow....Y....................................gallons.
WSeptic Tank—Liquid capacityvzj allons Length................ Width- ._ ----.---- Diameter................ Depth................
x Disposal Trench—No. .....I.............. Width............... Total Length..........................._. Total leaching area.._3.1_P sq. ft.
Seepage Pit No...._..�.-_-__-__-- Diameter.........4,.�.... Depth below inlet....}.!........ Total leaching area.3.S.. _sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by................................................ __ Date........................................
,4 Test Pit No. 1... 'a`...minutes per inch Depth of Test Pit---0-........... Depth to ground water....N_A_!.......
(i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 •-------•--•-----•------------•--•-----•------------------•••....-----------............•---•-------.........................................................
0 Description of Soil.........................................................................................................................................................................
x
U ---.......••--•---•--•-----------•--•••-•••----•-•--•-----••.....................••---------------------------••--........_..----------- .....----•---•---------------
w _
U Nature of Repairs or Alterations—Answer when a l'cable__._..___ _i,1��:0 JLse Y�.....•.. .�-1.�_®t'_� _________
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code— The-undersigned further agrees not to place the system in
operation until a Certificate of Compliance has*se board o health.
Si ned- = •--•----•--......---- --Application Approved BY ....... •-----------------••••.......
4. 5
Date
Application Disapproved for the ollowing reasons:---••••------------•.........•-----•-•--•------••--------------•--••---•-•------------•---------••-•-----.......
....................•----......---------...--•----•--------••-------------------••---------•-----•-------.....------•----•--------------------------•--•--•--•------------•---•-•---------•--••-••--_....
Date
Permit No...---.. ........................ Issued-..........4 -t---•g •------------.......•.
Date
' sr
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.......................................
App iration for Dispu,ial Works Tonstrnrtion ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
S stem at
7�' 'fYr "C- r<,'_ l�_'C%/}t7 '�%i� T?�r✓S /P,�4,,
• - ._......_ ......................................................... •••••..................................... __
� Location,;-Address C
{ 1 r�1� :, i-/-r- ?1:5004 ::-rG Le ��1ICT`5r/����'=%�fiN r�!lr ��-NO�'��l_�t�crl-
. ......................__......••-•••-• ......-
(� /!+Ur2+ t;JhJ /"/�. r) ,�'Jet> r+l/C.1 � rig'a
owner
........... - ............................... .......................................
$4 Installer :F -...-
U Type of Building Address /I m
Size Lot............................Sq. feet
.., Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic (f ) Garbage Grinder (� )
`4 Other—Type T e of Buildiil pa yp g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P., si I S . ther fixtures .............•--'--•-•- . •-- •----•--•-••-------•••••--•F-`- ...........................................
W Design Flow.....................I...........:,= >:gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacitf z2`''-gallons Length................ Width................ Diameter__-____.-....___ Depth................
x Disposal Trench—No. ............... Width....C.. Total Length......_........... Total leaching area_7%:?...a-----sq. ft.
Seepage Pit No------=------------- Diameter.........i_.._t..... Depth below inlet.__I�...I.......... Total leaching area--..3..._;;..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---•-••---•-••••-•••--•----•-...--••-•-•••••--•--•......-••'••---'----•••- Date........................................
Test Pit No. 1../_.D„___.minutes per inch Depth of Test Pit.. ^.j _...____ Depth to ground water.._IVA.(---------
(z Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 P4 -----------------------------------------------------------------------------•----•-••••-•-••-_..............................................................
Description of Soil........................................................................................................................................................................
x
U ..............................................-••--•----'-----'•----•-•---•-••-•-•--••-•-•-•-••-•--•--•-----•--"••----.....•••••......-----••-•••--•"--'••--•----'•---•-•••--•...----••----•-----••---
x ...•'•-•-•-•-•-------------•-----•'-•-----•-•......-•---•-••-••--•--•---•'•-••---......----•••••••-----••......--•-•-••-'----•-•--'•--•................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------••---------•------------•----------•-•-'---------....--•--•-•--------•-•------•---------------------------------•----------•-•----------------.........-•-••---•--••
Agreement:
The undersigned agrees to install the afored-escribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Godel The undersigned further agrees not to place, e�system.in
operation until a Certificate of Compliance has been issuea'%y the''bGard--of'heglth. f
Signed f �. J Date .._..
Application Approved By........... ,,,„ _ ...... ! = Y
A == .t Date
Application Disapproved for the following reasons:..............................................................................................................
--•--••-•-•----------------------------•.......-•--••-'•------------.....-•---'-•----....--•-••----......._...--------....--'------•----------------------------------•--•---'-••---••......-••••-----•-
Date
Permit No.--. . ..... `-' --------------•----_ - '
--•--- Issued_.---------�-----------_----=-;j=..----•-----...-•-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................................::......OF
z furdif iratr of Tomplianrr
THIS IS'TO C)ERTIFY, Tlfdttt e,-Individual Sewage Disposal System constructed ( ) or Repaired ( )
by - f .................... Installer
Ina iJ��'._..
r
has been installed in accordance with'the provisions of TITLZ. -5 of The State Sanitary Code as described in the
application for Disposal Works Construction`Permit No ..............'_:`._........__. dated_......__`=1.-.t..---------____....._..._.._
THE ISSUANCE'OF THIS CERTIFICATE SHALL NOT-BE.CONSTRUVDA.SGUAR TEE THAT THE
SYSTEM MLL'=FUNCTION, SATISFACTORY.
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DATE..... .. / 8 S
•••. ...........-- ------- ----•----- Inspector .......... •-••-••_...... .--•---.............•.._...---
THE"',COMMONWEALTH OF MASSACHUSETTS
fw i `
BOARD OF HEALTH
..............................::...........LOF........... :..:......:......:....................._.........................
No.....................:... FEE........................
Permission is hereby granted......-------- --- 1 N--_----A-y-i ��.-�._-'-----------•----------•--
-------------•-••---..............._....
to Construct ( ) or;Repair ( ) an Individual Sewage Dispos System
Street
as shown on the application for Disposal Works Construction Permit No%.—!' Dated.........`r_`L-.gS...........
•-•-•-•--•-••--........_•-- --•-••..........-•--••.......-----
DATE............. Board of Health
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FORM 1255 A, M. SULKIN, INC., BOSTON -
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LEGEND
EXISTING SPOT ELEV4T!^N Ox^ CERTIFIED PLO"! PLAN
EXISTING CONTOUR — _ 0 — — —
FINISHED SPOT ELEVATIUN [0.
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x; p EGISTERE REGISTERED JOB N0. G 3 2-8, BUILDING SHOWN ON THIS PLAN
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rs ENGINEER SURVEYOR DR.BY OF BARNSTABLE, MASS
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