HomeMy WebLinkAbout0380 WHEELER ROAD - Health 380 Wheeler Road
Marstons.Mills
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _
CIS
380 Wheeler rd
Property Address
-
Robert Frazee fw
Owner Owner's Name
information is '
required for every Marstons Mills Ma 02648 9/22/18
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness.checklist at the end of the form.
Important:When A. Inspector Information /334/
filling out forms
on the computer, Michael DiBuono
use only the tab
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Lane
reb Company Address
Cotuit Ma 02635
City/Town State Zip Code
508-364-9587 S113522
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
9/24/18
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
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i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1,- p
Subsurface Sewage Disposal System Form —Not for Voluntary Assessments
/y
380 Wheeler rd
Property Address
Robert Frazee
Owner
Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System contains a 1500 Gallon septic tank as well as a concrete distribution box and A septic field of
Y P P
pipe in stone leaching trecnh 32'
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l' �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is Marstons Mills Ma 02648 9/22/18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
I
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�x ,s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. 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"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
► Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� I
380 Wheeler rd
`I Property Address
Robert Frazee
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 9/22/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
i
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage d 239 Gpd
9 ( Y 9 (gP ))�
Detail
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
,�,p Title 5 Official Inspection Form
11e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Pumped every two to three years
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
3/21/95
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.5
p g feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
System is vented at the field
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500
r
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
23" �
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.):
System has been pumped in the last two years
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. ./` 380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box if present must be opened) locate on site plan):
Depth of liquid level above outlet invert Level with no signs of failure
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.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1 32'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No ponding no break out. Trench is still leaching
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.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
is Title 5 Official Inspection Form
�^ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below.
❑ drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Su _bsurface Sewage Disposal System Form Not for VoluntaryAssessments
Y
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
VeV`%
� I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is Marstons Mills Ma 02648 9/22/18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
C Commonwealth of Massachusetts
,1? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
380 Wheeler rd
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ .Surface water
❑ `Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: March 18 1986
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test hole data on plan
III
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
Commonwealth of Massachusetts
�x Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Wheeler rd
u
Property Address
Robert Frazee
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 9/22/18
�
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑ A. Inspector Information: Complete all fields in this section.
❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
_ > IL _a"
Fee-----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application,forlVell Con5truct ion Permit
Application ' hereby made for a permit to Construct (Alter or Repair ( )an individual Well at:
3?V _U)h4 Qlax � ) — M�t� nsl / _ - ( , O -09-7 ---
Location — Address 32,0 Asses sis
Map and Parcel
-—tI� Y _-- -
Owner Address
Installer — Driller Address
.Type of Building
Dwelling --- ———--—-
Other - Type of Building - No. of Persons------------------ --------
Type of Well ��r �P V�--- Capacity— -------- -----
Purpose of Well--� It-All- —
VV4
Agreement: / Ot���vz�,r,ti� 3✓J H�/V'e��. � 01"Zoyv
The undersigned agrees to install the aforedescriberd indvidua�well in accordance with the provisions of The
Town of Barnstable Board of He lth Pri a We rotection Regulation — The undersigned further agrees not to
place the well in operation until Wicof i plia ce has been ,issued by the Board of Health.
Signe
—� dte
Application Approved By — --- ------- 3 0 ----
date
Application Disapproved for the following reasons: ------------ ---------- --
• ---------- date
Permit No. cio?^ -3 — Issued (I -- --------
--—date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f (Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by--- —__.__-------__ _-----------
�) Installer
at �/�-2-Q- P r ,has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot ction
Regulation as described in the application for Well Construction Permit No. DatedTHE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector---- - ------ ------
No. � �-- Fee------
-1- -------
BOARD OF HEALTH
TOWN OF BARNSTABLE
;(ppiication for Vell Con5truct ion Permit
Ap licatio hereby ade fpr a permit to Construct ( �, Alter ( ), or Repair ( )an individual Well at:
3$ Wh.e Q.IC.Y 1Pcl. Ma�snsl�{t�rtS &V
Location — Address Assesso Map an Parcel -
- o� Q X er Yl C _Z e — —Sea_ - U,A Q.Y �. --_-
Owner Address—
CC,
Installer —/Driller Address
Type of Building /
Dwelling ✓ -_—__�_— —_—
Other - Type of Building- --- No. of Persons-
Type --------- -_-__
of Well VC' Capacity-------
P Y-------------------
Purpose of Wel' Z'—}a�?�� �Y.
Agreement: PV 4 V1 11
The undersigned agrees to install the aforedesc be individual well in accordance.with the provisions of The
Town of Barnstable Board of He te
Pri Wel otection Regulation - The undersigned further agrees not to
place the well in operation until 0.0 f o plia ce has been issueed by the Board of Health.
Signe
Application Approved By ------- 3 0 ?
i date -- --
Application Disapproved for the following reasons: ------------- ------- --
r date
Permit No. �/�1 UV 3�� '_ Issued 3-U ---� -- -----------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
C ertif irate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( . )
by -- -_- ---------—--- - --
Installer
at- 3 eo LA114-C L —l- ' >>f
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot ction
Regulation as described in the application for Well Construction Permit No. w.2�0-3V-Dated—����----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE—--- - -- Inspector------ - - --- --------—-
BOARD OF HEALTH
TOWN OF BARNSTABLE
Yell Construct ion Permit
No. — 1 �?____-3 7 Fee- ------
r �
Permission is hereby granted P! - `----�---------- -----------to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at:
No. ----------- ------------------------------
Street
as shown the application for a Well Construction Permit
No._ l� fl o,? 3 Dated 3 U7•_ ---- ---------------- -
--- -- - -----------------------------
3 Board of Health
DATE— __
FRUI : ROBERT P. F--R,,VF'F t'Cl . -200,? 32:30::'M F-I
...........
Fi
pi-
0115
1-7
b
CA,
, TOWN OF BARNSTABLE
LOCH SON l..y3'60 kelef AZ SEWAGE # ��5 3 3
VILLAGE In A) ASSESSOR'S MAP &LOW/1 t'7
1
INSTALLER'S NAME&PHONE NO. 5;"TV 6
!� SEPTIC TANK CAPACITY rao L
f LEACHING FACILITY: (type) (size) X
NO.OF BEDROOMS 5—
BUILDER OR �;R2 F— e�
PERMITDATE:_���+'6— COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells existIf
on site or within 200 feet of leaching facility) �`�� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist -`
within 300 feet of achin faci ' r0 7 Feet
Furnished by v .
�3� ;, �
r�� ��.
a ,�
�1t' �3'� �3 0
G �s
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IQ
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le
L03CATION SEWAGE PERMIT NO.
V 1-L LACE
INSTA LLER'S NAIME A ADDRESS
BUILDER OR OWNS
DATE PERMIT ISSUED
DATE C0 M P L I A N C E ISSUED
Q��R
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0
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o
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o
- - - _ - - J
No..... ... ..0...... -
THE COMMONWEALTH OF MASSACHUSETTS��
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for UinVuuttl Wor1w Tomitriirtiurt remit
Application is hereby made for a Permit to Construct ( ) or Repair (,'L ) an Individual Sewage Disposal
System at:
...............................
Location- lddrrss or Lot
No.
Owner Address
W
Installer Address
U Type of Building Size Lot.___ 15.?.-I....Sq. feet
►� Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons____________________________ Showers — Cafeteria
Other fixtures _______________________________ __
w Design Flow............. ra_______--______-_---____gallons per person per day. Total daily flow...........7`—�v gallons.
WSeptic Tank—Liquid capacity__`��___-gallons.-_r Length__ �+.�_�~. Width_S`.5----_ Diameter________________ DepthG._Z_` .
x Disposal Trench—No:.._.�.............. Width........c.s.-..Total Length------ z`.._... Total leaching area-----Z_r_a_L ft.
Seepage Pit No--------__-------- Diameter-_...__-_-_...__-.-- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Resu1 2 Performed by.-_..0VtW_ .. ! �R Date.....3.-3-_ 5..........
,a 10
Test Pit No. 1----------------minutes per inch Depth of Test Pit..- Deptli'',o ground water......�4/A- __-.
fi Test Pit No. 2................minutes per inch Depth of Test Pit__-_-_-__---___--_ Depth to�g7nd water.--.._......_._....___.
Q+' -----------------------------•-•••••---•-•-•------••-----•-•••••-•-•--------•-...........•-•--•••...---•---•---•.............................................
0 Description of Soil---------------P----�--••----•---�f-- ------- ------------------...3(. l M11VID...--------•---
vk........ - . •• -••-•---•- -•-••...•-- ---•--
w
UNature of Repairs or Alterations—Answer when applicable............................_............................................_...................._.
•--------------------------------•-••---------------------------------------------..........-•-•--•----•------....------------------------------------------------------------••-••-•-•-•---•-••-•-••••.
.Agreement: -' 1
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 Compliance ha een s ed b the 6 at ea h.
rS
SignedJ..l ................................ ---- -.: ....-----------
Dace
Application Approved By -------- ............ ......3=2 --9,s
Date Application Disapproved for the following reasons: ...................... -- .......................................................... --- .... ........
.. . . ........................... ... ... ..... ........................ .................... . . ............................................ -............---------------------------
Permit No. .........K�_-=...5.33- - ------ --------- Issued ............3----------Xt....... . .................
Date
a
No......j-5:533 �......'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratuatt for Di-tipinittl Works Tomitriirtinn rnmit
Application is hereby made for a Permit to Construct ( ) or Repair (JC ) an Individual Sewage Disposal
System at:
t ,
................ ..................................................4 1 2^'E . ( 2 ---�=•t�...........
Location-Address or Lot No.
.................................r. .,> r sl_✓J.Gd._
--••-- ---•---------------------------
Owner Address
W
Installer Address
UType of Building Size Lot_._. ....Sq. feet
1 4 Dwelling— No. of Bedrooms-----------------------------------.-:-_____Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons____________________________ Showers ( ) — Cafeteria ( )
al Other fixtures _______________________________ _ _
W Design Flow.............��.G........................gallons per person per day. Total daily flow_.___......�_....�__........__-__.___..gallons.
WSeptic Tank—Liquid capacity(__Wgallons Length._I_P._.� . Width_S'--U, ___ Diameter..._------------ Depth!�;.:-`a`'..
x Disposal Tretich—No. _.__1.............. Width......I.c S....... Total Length_____3 Z...____ Total leaching area..... ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Resul Performed by..__l�'L (__« _ ? �s. Date...._�>_�.�_7��. 5�......_..
Test Pit No. 1________________minutes per inch Depth of Test Pit--- U.�_ Depth to ground water_-____---
_r------------
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.--_-____-_--___.-_-____
9 •-••••••••••--------------•----•--•••---••--•------------•••---•••••--••--..._......---••---.....•--.........................................................
0 Description of Soil- 4 -------------------------`-'�-- --.-........ ------..��---------------
W ---_------------------------------------------------------------
_----------------------
.---------------------------------------.--------------------------------------------------------------------
N_.
U. Nature of Repairs or Alterations " Answer when applicable.______________.................................................................................
----•-•-••----------••-•----•••-•....._-••-•----•-••••••••••••••••••••••-••••••••...........-•.--•••--•••---•••••-••----------------•-•-•--•••••.....--•-------•--•---•---••••-••••••-•••--•--..........
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 Compliance has,"been issued by the board of health.
Signed ��........--- = ...�......... - -...... l ................
+.
V ` /i° Dace
Application Approve By ' Q ` ...:"a
-., - -------------------------------------------------------
Application Disapproved for the following reasons: ---------------------------------------------------------------------------------------------------------------------------------------
'pr ' P
------
..----
.................
-----------------
.----
.------
............................. ------.....-e------------------
t' Dace
r /' ;I � 2
Permit#No. ...... � J`�................_ Issued .------------3--"....�-/...-.?f�.
I * 1 Dare
I_...--.-------------- ,--.--- ——— - ----------- --------------vim.--------------"
THE COMMONWEALTH OF MASSACHUSETTS *--
BOARD OF HEALTH
TOWN OF BARNSTABLE
O'Lle tifi ate of ((��(1IImplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �)
Inse]let
�------ ZZ -,/--'._--------xl—k---- ------I." 111t---------------------------------------.....__---------------------------------------------------------
has been installed in accor
dance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ._.'�5.-. `� 7......... dated ��..^- -.L..-..� ......._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ _..---- . -- --------------------------- Inspecto >' E -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t q TOWN OF BARNSTABLE
N.......L.. .. 3 FEE, �.'a.. ... .....
�t�pn�tt1 nxk� ,�,an�trn.rttinn �rrmit _
Permission is hereby granted........................ ' !� � '
to Construct ( ) or Repair O an Individual Sewage Disposal System
at No.•-•••••...••-• G. ....�7 :.. s-<Q"' ........AA.... &> � ,
Street �^' 7
as shown on the application for Disposal Works Constructio � ermit No._�-_:_.�3_)- ted...........................................
Bard of Health y
DATE "~~ .................•• '
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
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