HomeMy WebLinkAbout0176 WHITE MOSS DRIVE - Health 176 White Moss Drive
Marsto is Mills IF
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046 �142
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T - - TONVN OF BARNSTABLE ;
-CATION /r 7��� T�� ®SS SEWAGE #
VILLA I GE MKS N"W'S. M(UA. ASSESSOR'S MA.° & LOT its'1�12
INSTALLER'S NAME&PHONE N0.
SEPTIC TANK CAPACITY
LEACH[NTG FACILrFY: (type) (size) 13
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: Y-/V` 4-3y COMPLIANCE DATE: 'f Ll'.3 Lb3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
� A G 4 ,;L7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i41oSs
Property Address
fib
l �C?
Owner Owner's Name
information is
required for every A/ S.. •/,Z ou 6
page. CityRown State Zip Code Date of Ins ection ii
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. Inspector Infor ation
/
on the computer, /✓ l
use only tie tab Q w•r /'e-,
key to move your Name of Inspector
cursor-do not
use the return
key. Company Name OVIE]
Company Address '— /U 4
Aa
t� City/Town S� State ! ,. Zip Code
Telephon umber ) License Number
f., B. Certification
• V
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I 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 s
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
C
Inspector 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.
Onsp.doc-rev.7/26/2018 -nje 5 ot�.dai Inspection=or:suosunaoe sewage Disposal system•Page 1 of 18
t'
J
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
fill
Subsurface Sewage Disposal System Form - Not for Voluntary Assessme is
'74 W/We 0 SS J�
Property Address
Owner Owner's Name l!r G Q
information is !'�
required for every ,
page. City/Town State Zip Code Date of Inspeftion
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System sses:
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:
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°, °nd2 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.00c•rev.7f282018 Title 5(75aai inspection Fora:suosurace sewage?sposai system.?aye 2 of 16
Commonwealth of Massachusetts
W.
INSIM Title 5 Official Inspection Form
9p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•� �i� 0 sS
Property Address
Owner Owner's Name
information is
required for every / da 6Yf cXL a-3
page. City/Town sta e Zip Code Date of Ins ection of
C. Inspection Summary (cons.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
1
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:
tsnsp.doc-rev.7/26/2018 -ite 5 Official inspection Foam:suosurface sewage Disposal system•Page 3 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Aa-
Property Address
Owner /n�information is Owners Name 4 //l �6 T(L O Q
1,�3 /,/,o
required for every i✓
page. C4/Town State Zip Code Date of Inspe 'on
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 sys-�em 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
eclogged SAS or cesspool
I! Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
tbinsp.Coc•rev.?262018 -ite 5 O5dai inspecbOn Fora:Subsurface Sewage Disposal System•°age 4 of 98
Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /
Owner Owner's Name j
information i� r �/_y� �/ C,
required for every J � 19-
page. Ci /Town State Zip Code Date of Ins ectio
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ tic liquid level in the distribution box above outlet invert due to an overloaded
LLL44Y�� or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
❑ Ran 1/2 day flow
equired pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped
❑ 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.
n Any portion of a cesspool or privy is within a Zone 1 of a public water supply
` j well.
❑ V 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.]
❑ e system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
r The system fails. I have determined that one or more of the above failure
—� criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes' or"no'to each of the following, in addition to the
questions in Section C.4.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
t5insp.doc.rev.726/2018 -itle 5 O`fdai Inspection Porn:Subsur;ace Sewage Disposal System•Page.5 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Volunta Assessments
76
Property Address y�/r
Owner Owners Name
information is 4 AAWS � 6
�3
required for every -
page. Cit f own State Zip Code Date of Insp tion
C. Inspection Summary (cost.)
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 C.4 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 GA 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
❑ �� --any of the system components pumped out in the previous two weeks?
❑ e 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)]
?iUe 5 otaal inspenon Qom:subscrface sewage Disposal system•Page 6 of 18
tsinsp.da'rev.7252018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary�Assessments
0�
Property Address
y
Owner Owner's Name
information is gas NS D required for every y
page. City/Town State Zip Code Date of In ection
D. System Information
.1. Residential Fow Conditions: 2
Number of bedrooms (design): Number of bedrooms (actual):
33a
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
/ /JUGam►Ah .� << '1G �v
i�r,b�o1, 6'
Soo A o Chot*,"Le (4*
og.S_--"e
O
Number of current residents:
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 PeNo
information in this report.)
Laundry system inspected? Yes No
Seasonal use? Yes to
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
❑ Yes o
Last date of occupancy: to
t5insp.doc-rev.7126/2018 Title 5 omdai irspecdor,=crM,su:.suface Sewage Disposal system•Page 7 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
b • I T II��
Property Address
Owner Owners Name
information is1 �^_
required for every �.(��
page. City/Town State Zip Code Date of lnsp ction
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 mete-readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
A//Z4—
Was system pumped as part of the inspection? ❑ Yes o
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.aoc-rev.7262018 7iUe 6 7fflciai inspect on Form,Subsurface Sewage Disposal system•?age 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is ,4
required for every
page. City/Town State Zip Code Date of In ection
D. System Information (cont.)
4. Type of S em:
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):
in
Approximate age of all components, date installed (if known)and source of �p rmation:
Were sewage odors detected when arriving at the site? ❑ Y s ' o
5. Building Sewer(locate on site plan):
Depth below grade: 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.):
-tUe 5 0�cai inspection corn.sucsur!ace Sewage Disposes system•Page 9 of 18
4insp.doc•rev.725/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for every /V,Iley 49
page. City/Town State Zip Code Date of Inspectioff
D. System Information (cons.)
6. Septic Tank (locate on site plan):
Depth below grade: �-
feet
Material o =nstruction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions.-
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thictness
r/
Distance from top of scum to top of outlet tee or baffle
Distance From bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Commerts (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
4., as4tl
C-,-;70L- 4-C.PS ✓1 0 6NCl/4i017
?age 10 of 18
LRnsp.doc•rev.725/2018 tue 5�oai Inspection Form:Subsurface Sewage Disposes System•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
5. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
AOSY 4aol—
Property Address /�N �k
Owner Owner's Name �s
information is Oa 6 W a'
required for every
page. City/Town State Zip Code Date of Inspq6tion
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of cons--ruction:
❑ 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.):
S. Tight or Hold-ing Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of ccnstruction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
?itle 5 of`aa'.inspacuon'Form:suosulace sewage Disposal System•Page 1 t of 18
t5insp.doc•rev.7/2612018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
ti
Owner Owners
information is
required for every
page. City/Town State Zip Code Date of Inspe lion
D. System Information (cons.)
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
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.):
� say
s (149
T;tle 5 Of Qal!nspectOn Form.SuDsU-lace Sewage Disposal system•?age 12 of 18
t5insp.00c•rev.7262018
f
Commonwealth of Massachusetts
oTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w0
Property Address
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of In pectin
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working ordet: ❑ 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: 6 I!0�1 C4&si, ,F
0 leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativelaltemative system
Type/name of technology: --- —___ —
Tine 5 ot5oai insoe�von=c,:Sl'DsffaG2 Sege Disposal System•?age 13 at 18
t5insp.doc•rev.'12512018 '
Commonwealth of Massachusetts
1.9 Title 5 official Inspection Form
4 Subsurface Sewage Disposal System Form lNot for Voluntary Assessments
Property Address 19C
Owner Owner's Name
information is
required for every bb yy
page. City/ own State Zip Code Date of Inspecti n
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.):
0OHNe n s l� GNL✓
Sol 0 C>6 os
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.):
Title Otfoai inspection=o'm:S,sun`ace sewage o;sposai system•Page 14 of 18
L5insp.0oc•2v.7262018
• Commonwealth of Massachusetts.
:. Title- 5 Official Inspection Form
i.' Subsurface Sewac.e Disposal System F/orm�- Not for Voluntary Assessments
Property Address N
Owner on is Owner's Name ) /
required for every
page. Cityrrown State Zip Code Date of Insp tion
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.7/252018 'sue 5 Cffioa Inspeccon=orrn.suoscrface sewage orsposw System•Page is of 18
r
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
N \P
Owner Owner's Name l
information is �' s /�1/'El/, r1 �J
required for every YYYYlIOOJJfffG���� ` tate Zi�/o�(p T p d�
page. City/Town Sp Code Date of Insp tion
D. System Information (cons.)
14. Sketch Of Sewa Disposal System:
Provide a vie of the sewage disposal system, including ties to at least two permanent reference
landmark r benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the bu• ng. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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-ray E G i
Corp Qle✓ Corp i
bec a" Foot
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t6insp.doc.rev.7/2 612 0 1 8 Title 5 Offidai lrspeaor=om:subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
LA4
Property Address '
Owner Owner's Name
information is
required for ewry
page. City/Town State Zip Code Date of Inspe 4on
D. System Information (cons.)
15. Site Exam:
LI Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated dep:.h to high ground water. 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
❑ served site (abutting property/observation hole within 150 feet of SAS)
Checked with losal Board of Health - plain: 7a
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must de ibe how you tablished the high ground water elevation.-
0 u lOC�
!oti/ P-, t
C4 �l
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
5insp.doc•rev.7262018 -ive 5 075cal inspearon For:SuDsutace Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address r�/
Owner Owners Name
information is / / //.�ll// "
required for every �N � /� S //� (�b/(� � 11 � e�-•� T
page. Cityrrown State Zip Code Date of In pectio
E. Report Completeness Checklist
Complete all licable sections of this form inclusive of:
A. In tar Information: Complete all fields in this section.
rtification: Signed & Dated and 1 2, 3. or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 mpleted as appropriate
4 F i ure 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
t5insp.doc-rev.7/26/2018 'iue 5 Gtmai nspecuon Fonn:Suosurtace Sewage Disposai System•Page 18 of 18
r No. ! 03— (S Fee
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPYicatton for Mtgonl *p5tem Con5tructton Vermtt
Application for a Permit to Construct( )Repair( V111upgrade( )Abandon( ) ❑Complete System 34dividual Components
Location Address or Lot No. i�� er's Na(mme,Address and Tel.No.-
in
Assessor'sMap/Parcel 14H �� ' "' `TZ0``
IVIN dre s�„a� Te 1 r dd ssnd .NQ(v � J
6 V/1 Oda
e,¢
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per,day. Cal ulated daily flow gallons.
Plan Date Number of sheets 22 Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisiY9,of Title 5 of th Environmental Code and not to place the system in operation until Certifi-
cate of Compliance has been i o ea h.
Signed Date 44163
Application Approved by Date 4 tc 6 3
Application Disapproved for the following reasons
Permit No. 200 3_ 1 S$ Date Issued 1 0 3
NO. Zoo3" 'S� Fee ✓`'.F` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I/
Yes
r`
PUBLIC HEALTH DIVISION = TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppfication for Mtgogal *pgtem Congtructton Permit
Application for a Permit to Construct( )Repair( Voupgrade( )Abandon( -) ❑Complete System EL9 dividual Components r
r Location Address or Lot No. ( j n I er's Name,Address and Tel.No.
Assessor's Map/Parcel O,1 j ^( I► 2 h M `
'{
Installe 's Name,AddreAss??.an�jTe�" o, { (� r i Desi/name 'ys'�Iame>Address�ayn�d Te eNo. �— { �
�� Iv IL.�1 / / k� /�I ' GL�
Type f Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow _gallons per day. Calculated daily flow gallons.
Plan Date n Number of sheets /� Revision Date
Title
Size of Septic Tank Type of S.A.S. % , (Aa,m
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) _ f
Date last inspected: *z
Agreement: ,
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provision's�of�Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been$jT/`V
/this Ro ��o Heal
Signed Date '7
Application Approved by Date `r I lc 6 3
Application Disapproved for the following reasons t
Permit No. Date Issued 1 b 3
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERY that the On-site wage Dis osal.Syste ,onstructed( ) Repaired( )Upgraded(✓)
Abandoned( ,)by t
at -r(P o)Df has been constructe in apcordance
with the provisions�of^Title 5 and th o:Dis osa ystem Co struction Permit No. �03' 1 S$ dated `-( (L U 3
Installer (AW KI IWM Designer ^�
The issuance,,o tAs pe shall not be construed as a guarantee that the system w' �iz�ct o designed.
Date "7 f Z J/l Inspector
---------------------------------------
No. Zoo 15-b Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migpogar *pgtem Congtruction Permit
Permission is hereby granted to Construct(` epair( yU grade( Abandon( )
System located at -�"�0 ( � T I Yy tDJ �w )
and as described in the above Application for Disposal System Construction Permit:The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. ,
Provided:Constfuctidn must be completed within three years of the date of thisM. -
Date: � �'�� Approvedb
Y�
TOWN OF BARNSTABLE
LOCATION ���� fr ®SS a SEWAGE-.#
VIMLAGE_ /ASSESSOR'S MA.D &SLOT b4 b' 1q1-
INSTALLER'S NAME&PHONE NO. /�! 72i4 — �$S"'
i
SEPTIC TANK.CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: D3
I
I Separation Distance Between the:
�f Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist,
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
12,4
C'F
i7
I � F
D ,-�i .
3(0
7C/
� P
I
4'
'M�25T�tJ
G�ll QED a
C11
S�a�2�co
k TOWN OF BARNSTABLE
LOCATION L IJ� iQS 1,� SEWAGE #
1 . % Oyb /y v o 1 -oe
VILJ�,�AGE OAS Kyt-LS ASSESSOR'S MAP & LOT 00 ���
�, •d
INSTALLER'S NAME & PHONE NO. !b. �7 7 3 L t
r SEPTIC TANK CAPACITY
00 LEACHING FACILITY:(type) T IT (sue) o GE1 6
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
VIPBUILDER OR OWNER_4:����
0 r
cP DATE PERMIT ISSUED: 3 r ( 9:1
DATE -COMPLIANCE ISSUED: 3 -7-1 - 7
VARIANCE GRANTED: Yes No ✓
__
!�
•,
� i
3N a�j
3
�o i ��
• TOWN OF BARNSTABLE
LOC-A.1ION ' `� W�n�T'� �-t ��- SEWAGE #
VU:LAGE� ASSESSOR'S MAP & LOT
INSTAIALER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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 exist
on site or within 200 feet of leaching facility) Feet
Edge,of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)
Feet
shed by ��CJ�
` r �
4s�
N
se ��`
{ 'SESSORS MAP NO: ._._.-
"3'- 01 1
PAR( NO. _ �1l_— W5 DI
No...2_7..I6--y.. Fig.... �::............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4.
cr .--.oF.-.-..-. T -------------------
ApplirFatiun for UiipugFaf murk C�unutrurtiun rrutit
Application is hereby made for a Permit to Construct _ or Repair an Individual
pp y ( ) p ( ) al Sewage Disposal
System
L c 'on•Add r s or.Lott No
.24
---------------- --------- ------- �-----------..........--------------.._..__........------.....------
Installer Address d Type of Building Size Lot______J_?a4.b_Sq. feet
U Dwelling—No. of Bedrooms.......... ._.._Expansion Attic ,(V&) Garbage Grinder 046)
`4 Other—Type T e of Building No. of ersons____________________________ Showers
a, YP g ---------------------------• P ( ) Cafeteria ( )
.< Other fixtu es .._..•-••---------•------------- -
--•-•
W Design Flow__________..6._ ________________________gallons per person per day. Total daily flow.................-_��...............gallons.
9 Septic Tank—Liquid capacity._I _gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area____________________sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) j
Percolation Test Results Performed by-__.��: _..:--C1�1.1 __�i�n2e��� Date......114.6_1-
minutes per inch De h of Test Pit____________________ Depth to ground water______ILgr�i____ .Test Pit No. 1.__._.�__._ -
0 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a - --------------- - •-----•-------•----...._.....----........._•---------•---_..._......•----•--•---•----•-•---•-•••--------•--•..._....-
Description of Soil....Q--- ��F ---� !t_�...
W
--------------------•---•-•-------• -J r1 :. f_. _r .�..--MCA ____----_---_------ -
Z -------------------------------- -•----------------------------------•------•---•-•----••-----•---•----•-•--•-•------•-------•-•-------•-•--------------•-••--•------•-••------------••--••--•-•--••--•-
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 i 1 i 5,of the State Sanitary 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....-•- - ---- ' . �_6&40-----------•• ----
Application .Approved BY �`� �� �/ '`._�._.�..------•_________________________________ ..........3-^-
J Date
Application Disapproved for the following reasons:---------•--•------------------••----------------•- ..........................................................-
--•-•--•--•----------------------------..........................:................................................................................
Date
Permit No....�1--...ts-y-----•------------------_ Issued--------- - = �i------••-------
Date
No------------------------- .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�7 A.-I --------------------
---616<j V.....OF......... .7
Appliraffou for Ubipviial Marks (fatuitrartion fIrrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:,
............ ............
o._ ion-Ad .ey or Lot No.
.... ............................ ....6,.F,
0 Address
............................... ........ Jel----------------------------------------------------------------------
Installer Address
Type of Building Size Lo
t.... 4 ..Sq. feet
U
Dwelling—No. of Bedrooms___---_-3......................... ...Expansion Attic/(4) Garbage Grinder
Other—Type of Building ............................ No. of persons....._............__._______ Showers Cafeteria
Other fixtures .............................................................................................................
--------------Z-----------------------------
Design Flow.._....... .........................gallons per person per day. Total daily flow................: ::242................gallons.
04 Septic Tank—Liquid capacity.j!0V..gallons Length................ Width_............... Diameter---------------- Depth................
Disposal Trench—NTo..................... Width...._._._....__..... Total Length......._._........_..................... Total leaching area-------_----------sq. f t.
.
Seepage Pit No--------------------- Diameter.................... Depth below inlet..............._.... Total leaching area..................sq. ft.
Z
Other Distribution box Dosing tank
Percolation Test Results Performed by.ln-ev' Date.. I
. .........L--- ---------------of Test Pit.................... Depth to ground water____)'kolylt-------
Test Pit No. I-----:7�--___minutes per inch t
Test Pit No. 2................minutes per inch Depth of Test Pit.._............__... Depth to ground water........._......._.._...
------------I--- ............ ................. ................"--------"--------------------------**-*-,*------------
0 Description of Soil... a ..................................................... ..........................................'71-----V ."
�4 ........ A . .................................................................................. C4
U
.................. .....................................................................................................................................................................................
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 T I T-L-14, 5 of the State Sanitary 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... .............. 17,
7 Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:..............................................................................................................
........................................................................................................................................................................................................
Date
Permit No....... IssuedL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............r.Q.9J.Al......OF.....
Tatifiratr of TI-Intlifiatta
THIS-1,S' TO CERTIFY, That.the Individual Sewage Disposal System constructed './) or Repaired
..........f .................................................................................................................................
by-------- otz
Installer
at.............. .........�..S........L'i, _Lf-tZ /V.'6.Sf5......2,
has been instilled in accordance with the provisions of T I TIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............:3.....-_.:)a......... .................................. Inspector.... ....aA .. ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...
FEE....
Disposal Workii TIMmitrurtion ramit
Permission is'herebv granted...........-JAUITI&Z's........_"'h ..6e..........................................................,911.S.Q6
or Repair an Individual Sewage Disposal System
to Construct &/)
t ........ . -4
.... ........................
Street
as shown on the application for Disposal Works Construction Permit .Na....................... Dated.__.._._.__..._....._......_..._..........
................... . .... ..... ..... ----------------------------
Board of H'ealth'
DATE........2........... ..............................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
t 16
B�F�,xOUT CA C.vc.-�Ti oNs.
i o X isa 3 U z 32
ir
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Lc;-•r 11 9b w
1
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0
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LEGEND I
EXISTING SPOT ELEVATION 0 �
PROPOSED SPOT ELEVATION ( ] �P� of Mq s j �!OF!
EXISTING CONTOUR 0 q 1
PROPOSED CONTOUR 0 �o� P A U L cti� IN
NOTE: THE LOCATION OF ANY UNDERGROUND A.
SEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON LEVY a N'L 341
THIS PLAN IS APPROXIMATE ONLY AS DETERMINED A �F o.ioo5��0
FROM RECORDS AND/OR VERBAL INFORMATION. �o� G/STE TE
}�THE CONTRACTOR !IS RESPONSIBLE FOR THE FSsioN tiad La�os Cz,
VERIFICATION OF THE EXISTING LOCATIONS IN
THE FIELD. ,
N i TEgg �aug
,..
LEVY 81 ELDREDGE ASSOCIATES:INC. cLIENTQCL PRASE- PLDT PLAN ry
ENGINEERS- LANDSCAPE ARCHITECTS JOB NO.L�„_, �D�- 5'` h �r - 5 � �
PLANNERS - LAND SURVEYORS ^--°°�°�° -- -— •— ' `
OR. 8Ys _
IN
889 WEST MAIN STREET CHKD.BY,
CENTERV I LL E, MA. 02632 SIET,_1..OF SCALE. ,l'. � OATS_ 01 `'
20 FT• M//V. /Y07"E ../F /7'NER ?'NESEPT/G 7-i4N/C OR
LEACHING P/T ARE /YORE 7WAJ1/ /2"dEI-O.&V
_¢' - � P7: MIN 4'O/R. GRAO�j AI 2¢"O/AMETEK C'O/yCR�T.� COIiE�C
SCL/Eo(144 40 SJ+rALL Q.F BROUGHT TO 4,TA
CONCRL�TE PV.C. PIPE NE,4VY CAST/RO/Y COVER Sfl.44L L3,E !/SEO
44, 95,0 M/IV. P/TCN
� CODERS � � /F/N .DR/✓EwA Y
/a aE,P tT.
2•i4. M/N. CONCRE TE
_ _ I3Jr•4oE CO1�ER CLEAN SA/VG
BAC.+-F/L I-
j
.. SCNEVUL640 - - 2•LAYFR
/000 0 00'._ Poo OF �8•-3IB••
Gi4 L. ..
M/N.PITCH
• D I ST. • e • • • • e •• • o oA o /�{/A S.�IPD S727NE
SEPTIC TANfC • • o s • • . e , 4
j BOX o • • $ � • o •• � .�o •+
Or p o o . •E/'FECT%VE' r • •► 3/4• �2~
• • • DEPTJ4/ • • • ' Pa WA5RE0 STONE
//3 x !.0 =/�,�.0 �P1� . ' �� o • • • • • • , Plop,o PRECAST SE.--PAGE
INY.�'RT E'LENAT/ANS ►• • • •. • • • • , a 0 P/T DR EQU/V.
Ar
OWYAOET AT ®'u/LD/NG 97• FT Q, C9�17 6 F7: D/AM.
J/VLET .�EPT/C 7 4/VK •/O FT w FT M. •i �SEg TRSUL4TJON,
007407-SEPTIC 7-A V K ff .76 FT, r
lN1E'!'OJSTI�/�!/TION B01c�� •3b FT, SECT/ON 4F' GR04WO W,47,ER TABLE
OtlTL�'TDI ST�4/BUT/ON BOX •94 FT, SEJ�/AGrE OldS'POaSA L SYSTE/YI//VLJET.d�ACHMa PIT FT, TAQu1A?!D/V
1 EACH/NG p/T D/MENSI AN A S FT.
dPESIS V CR/TER/A sca
do/**WN5/O A/ B FT.
mumaE'R OF®EzxROOMS
c��eA6Eo/sPosaL uwlr/J(_o�/ SO//- LOG
TOTAL &WriAl.4TE.0 t=Lo*vX_G.41-.10Av SOIL TEST -SOIL TES77*2 SW AL 'TEST
A/UMBER 0,0r LeACNlNT OITS-Jr�
OA ..:
SlAE Lri4CHlNG PER P!T 5 PT it TE OF SO/L. TES T
0�-2/ Tom RESI/LTSh//TNESSED BY T �G1S�c
t�OTTOM/.�4C'N/NG PEIt P/T Sq, �T. ' A&rA LATIO RAT
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'll TOTA1 lF.o4CH/NG �4REA SQ T 2 _12� P0NC0l-A7y0NRA7"E j*Z M/N�IIVtH
RAMERYE4EACN/V6 AREA SQ. FT
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9
P A U.L.A
o
No.10050 O • LEVY & ELDREDGE ASSOCIATES INC
�0 FG/gT \�� L 79'S 889 WEST MAIN STREET CENTERVILLE,MASSACHUSETTS 026:
S
•
.
W � NOGROUNDNA yTER E 11N "ER
NCOTE'o-: ..- CL/ENT,� _
�F�i/E�/EAR 0.4TE r 2 ' >�
GRDU/VD W.47,1!:-R AT EG,E•f!. :
V �
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A*
DEPARTMENT OF ENVIRONMENTAL PROTECTION MAR
2 8 1997
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 "WA10F
HfA(HAS aSTA81
WILLIAM F.WELD UDY C
ti~
Governor r�t
ARGEO PAU:,CELLUCCI DAVM B. STRUHS
Lt. Governor Commissioner
O4 (0
I � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
I IJ CERTIFICATION
Property Property Address: 1-2-6- W q,rk f o5S -r. '(Q�J)LrLt//SAddress of Owner: �Q � f rKit rt S
Date of Inspection: v3 ��cf (If different)
Name of Inspector: M, � ���\_C
Company Name, Address and Telephone Number:
R!'LAwsr1L Eti`\C.L�•k�L��r.a�.,�t•U�cw a"�yt `�nS•n?«. Mn . oZt�yq cSutii� �117-\�y2�
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If t.ne 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes,.no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 11/03i95) 1
w
i� Printed on Recycled Paper
�-►.��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
i CERTIFICATION (continued)
Property Address: 19' 6 a_2&.:_6F ,_[ASS �'"• �"�pa a'►o w� U t S .
Owner:
t� Date of, nspection: /
_B].SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distr ution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The syste will pass inspection if(with approval of the
Board of Health):
broken pipes) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALT
Conditions exist which require further evaluation by the Bo d of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH D RMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a su ace water
Cesspool or privy is within 50 feet of a rdering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF EALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MAN ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank a soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has aseptic to and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic t 'k and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a w I water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
3) OTHER
(revised 11/03/95) 2
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
// CERTIFICATIONS(continued)
Property Address: 6 t-eos g ►"• ��+�+��O u-s I S . j
Owner: /� "Cy> � S
Date of Inspection: J
0 3�1�1�3
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as clef ned in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to dete mine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or cl gged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface water due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an ove oaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volum is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clo ed or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is bel the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface ater supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a publi well.
Any portion of a cesspool or privy is within 50 feet of a priv a water supply well.
Any portion of a cesspool or privy is less than 100 feet but reater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been an yzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia itrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to t criteria above:
The system serves a facility with a design flow of 10,000 or greater (Large System) and the system is a significant threat to
public health and safety and the environment because o or more of the following conditions exist:
the system is within 400 feet of a surface dri ing water supply
the system is within 200 feet of a tributary o a surface drinking water supply
the system is located in a nitrogen sensit' a area (Interim Wellhead Protection Area OWPA) or a mapped Zone II of a
public water supply
P well
The owner or operator of any such system shall bring t system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please cons It the local regional office of the Department for further information.
(revised 11/03/95) 3
b`a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Dr•
Owner: " 0 p 4-A'D/2/'5
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
�/
Property Address:
Owner: ,q P
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:�' C) all n s
Number of bedrooms:_Q3
Number of cur-ent residents:
Garbage grinder (yes or no): 0
Laundry connected to system (yes or no):-14aS
Seasonal use (yes or no):LoD
Water meter readings, if available:
Last date of occupancy: s 2w.
COMMERCIALINDUSTRIAL•
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SycT4w. Puwva&A S A o c �
System pumped as part of inspection: (yes or no)�d
If yes, volume pumped: eallons
Reason for pumping:
TYPE OF SYSTEM
_ Septic tank/distribution box/soil absorption system
Single cesspool
Overflew cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: S
Sewage odors detected when arriving at the site: (yes or no)tJ(]
(revised 11/03!95) $
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
L SYSTEM INFORMATION (continued)
Property Address: &UL 2� �oss ��+. �0u• 1`�-�I�S
Owner: d V
Date of Inspection:
SEPTIC TANK: Sr5
(locate on site plan)
Depth below grade: kv*6%t^—�
Material of construction: _&concrete _metal _FRP —other(explain)
Dimensions: k00C>!5 .k
Sludge depth: (w"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: '�_
Distance from top of scum to top of outlet tee or baffle: IC>
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Der. ja QQ o.%r"C� —C�s` t� c� lactiv.M (A-k emu.—Q kl�
GREASE TRAP:-L-)O
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP_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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1?t- l� 1 r°os5 Dr. )tr S-A--S /`"L vC S
Owner: R & p �IZ-ls
Date of Inspection:
TIGHT OR HOLDING TANK: 00
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: eallons/day
Alarm levei:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:-(' !>
(locate on site plan)
Depth of liquid level above outlet invert:-L�-U wl Ou-tL:r
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
6-4
PUMP CHAMBER:1uI-%
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: X o. P ��
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: lox y
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of ve et tion,etc
c
�T �c 5mu9�
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:J�JQ
(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.)
(revised 11/03/95) 8
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �� � /"�oSS
Owner: < '/— p
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
16
MASS
1
1
�c2 — 36t p 7 Z.'
3�3IA -
DEPTH TO GROUNDWATER
Depth to groundwater: 't 30 feet method of determination or approximation: U.S. o\ \L (�� CQ
(revised 11/03/35) 9
F
COMMONWEALTH OF MASSACHUSETTS
UV EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PR UMNVED
FAILED INSPECTION MAR 1 7 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 176 White Moss Drive
Marston Mills, MA 02648
Owner's Name: Paul&Pat Mazzola
Owner's Address: Same
Date of Inspection: March 6, 2003
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map: 046
Osterville,MA 02655-0049 Parcel. 142
Telephone Number: (508) 862-9400 Lot: 15
CERTIFICATION STATEMENT
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
Neods Further Evaluation by the Local Approving Authority
✓ Fa' s
Inspector's Signature: Date: March 9, 2003
The system inspector shall su t a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of comple ing 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 176 White Moss Drive
Marstons Mills, MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
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:
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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2
Page a of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 176 White Moss Drive
Marston Mills, MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
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
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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 176 White Moss Drive
Marstons Mills. MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
Yes (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 176 White Moss Drive
Marston Mills. MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
5
s
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 176 White Moss Drive
Marstons Mills, MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 5
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Launly system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type.of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 1997-per owner
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Afar. 27187-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 176 White Moss Drive
Marston Mills, MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 30"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. Recommend installing risers on the covers.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
f
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM S EM (continued)
Property Address: 176 White Moss Drive
Marstons Mills, MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: --
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was located, but not dug up. Liquid was backing up from the leach pit.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 176 White Moss Drive
Marston Mills, MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 4'x 6'-600 gal.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Irinovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):
Liquid in the pit was above the inlet pipe and up to the cover. The leach pit was in hydraulic failure. The bottom to grade was
approximately 9'. The cover was approximately Y below grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
I
9
f
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 176 White Moss Drive
P
Marston Mills. MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
Map:046
Parcel: 142
Lot: 15
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
A 8
V- 3�.
a rC �+
3 O
A
3 3 9 C,
y S� 13
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 176 White Moss Drive
Marston Mills. MA
Owner: Paul&Pat Mazzola
Date of Inspection: March 6, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40' +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barntable topographic map and the Cape Cod Commission water contours map the maps were showing approximately
40'+/-to ground water at this site.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report.
11
SETe- ASSESSORS MAP: 4�
TEST H O L_ E: LOGS NOTES:
� PARCEL: 1 'L
l >> 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
LOOD ZONE: �C SO I L EVALU TOR :1/. Me 'tt S C•Se THIS� PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF WITNESS : u �
BOARD OF HEALTH REGULATIONS.
REFERENCE: CATVI f- / DATE: MA94J4 Z5 2Uo3 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
C�j� LST' W1Y/7'� PERCOLATION RATE:: L Q r��E} SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
CLAS51 SOIL. = G•7(_19 ��Z. INSTALLATION.
�r
�� p TH- I EL.QO 31 TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
a \ A SftND/ Idyll ONLY, I qD IOSHALL NOT BE USED FOR PROPERTY LINE
1
4a l,Aktil -��•��
SRkDy IOYRS/g 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS
g Low SPECIFIED OTHERWISE)
LOCATION MAP(N:t.S) r -��'� 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
► I 41l /J
I 14\E.01 u&A a'_ GARBAGE DISPOSAL.
I I i SfttJ D 7 5 7/ 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
�{ ' �5 MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
i 1 i A BASE OF 6 OF CRUSHED STONE.
i 1 132" sI 7) E145176�4._GE*7(* PIr To Be PuMI��� c{tv� �FrL�p
I 9' PE k- 717-LE V Wui
g� N6 rwowtJ PIZ veg V�I 4,$ W l,v /SO v PRDA95a& (. 4cwmG.
o• �.. �_ ___ �_______�_
WF_-t L os w m) 1561 ar- PgoPo5Eo lEAofl
SEPTIC: SYSTEM DESIGN
/o,_Ap 4J2/fr-NGE$ �l�M T(,G�/ ��.IrU.l�Iv..�G............v........._...
N
FLOW E:T I MATE Aw T�? t,Tr w Rrr�l vc,r4 r ont.
II BEDROOMS AT 110 GAL/DAY/BEDROOM • 330 GAL/DAY
tI SEPTIC TANK
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DUXBURY, MA 02332
3 DATE HEALTH AGENT (781) 585-0293
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