HomeMy WebLinkAbout0190 WHITE MOSS DRIVE - Health 190 White Moss prive
046-145 Marstons Mills
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Commonwealth of Massachusetts
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=. Title 5 Official Inspection Form
' �ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,
190 White Moss Drive ;
Property Address i
Christopher and Tania Myers s
Owner Owner's Name
information is Marstons Mills
required for every MA 02648 08/21/2020 ;
page. Citylrown State Zip Code Date of Inspection
i
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 Information 6
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
� Company Address
Teaticket Ma. 02536
City/Town State Zip Code
� 508-280-3356 S13938
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
08/25/2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.
t5insp.doc•rew.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
f
Commonwealth of Massachusetts
�w = Title 5 Official Inspection Form
k Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. City/Town 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:
This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a leaching pit.
At the time of the inspection no visbile failure criteria was found.
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 dank 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-ref.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
tip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.; 190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
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):
❑ 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(11)(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
i
Commonwealth of Massachusetts
�v l� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e / 190 White Moss Drive
u—
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
0
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
El ® 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
t5insp.coc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.............. 190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. Cityrrown 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 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. 11
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
El ❑ 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
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
< � 190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. City/Town 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is Marstons Mills MA 02648 08/21/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus
GPD
Description:
Number of current residents: 5
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry cn a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d town water
9 ( Y 9 (gP ))�
Detail
In 2019-136.,000 gallons were used and in 2018-120,000 gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupiedDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. City/Town 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:
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. Cityrrown 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:
1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 32"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
i
Distance from private water supply well or suction line: town water
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 24"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
H-10 1000 gallon
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle
32"
I
Scum thickness 3-1
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the baffle was in place.
t5insp.coc-rej.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
(_ 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 White Moss Drive
u
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is Marstons Mills MA 02648 08/21/2020
required for every
page. City(rown 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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
tiI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r;
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
inquired fcr every on is
required Marstons Mills MA 02648 08/21/2020
page. Citylrown 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 01.
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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc•rem.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working 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: One
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rep.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
f
Commonwealth of Massachusetts
�n = ip Title 5 Official Inspection Form
X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... . 190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
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.):
At the time of the inspection no visible failure criteria was found.
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
I� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. Cityrrown 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- '
Title 5 Officia[ Inspectiyoim Form -
Subsurface Sewage Disposal System Form-Not forVo.luntary Assessments,
190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner
Owner's Name
information is Marstons.Mills. MA 0264�8 08/21J2020;required for every '
page. Cityrrown. State. Zip Code;` Date-of Inspection.
D. System ffif rrnation ),
(cost
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`p:ublic,water.supply'enters ;
the building.Check one of the'boxes below:
® haiid=sketch in the area below
❑ drawing attached separately - ==
4 1
t5insp.doc-rev.7126/2016 Tftle,5 Official Inspection Form-Subsurfwse Sewage.Disposal System+Page-16'of.t6� '
x.F -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,�- 190 White Moss Drive
Property Address
Christopher and Tania Myers
Owne- Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. City/Town 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: 14 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a hole at lower elevation and shot it with a transit.
tv
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.coc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
nLl Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!� 190 White Moss Drive
Property Address
Christopher and Tania Myers
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/21/2020
page. City/Town 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
t5insp.coc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 190 WHITE MOSS DR
Property Address
RABEN +�
Owner
Owner's Name t
information is a a9
required for MARSTONS MILLS MA 02648 11/5/15 M.
every 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 filling out A. General Information
forms on the 3
computer, use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC .
Company Name
VQ P.O. BOX 145
Company Address
CENTERVILLE MA 02632
'e00A City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11/5/15
Inspe is Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�0�1)VS
t5ins•3/13
Title 5 Offiaal Inspection Fonn:Subsurtace Sewage Disposal System•Page 1 of 17
iL
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 5, 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
AT TIME OF INSPECTION SYSTEM MET OR EXCEEDED ALL PASSING REQUIREMENTS. THIS
REPORT CAN NOT PREDICT THE FUTURE PERFORMANCE OF THE SYSTEM UNDER THE
SAME OR INCREASED USE. SYSYEM APPEARS TO BE ORIGINAL FROM 1987
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exMtration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M „ ' 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
required fo is MARSTONS MILLS MA 02648 11/5/15
required fo�
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The.system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
b , 190 WHITE MOSS DR
Property Address
RABEN
Owner Owners Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every cage. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
3 per
Number of bedrooms(design): assessing Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
l5ins•113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D-BOX AND
A 600 GALLON LEACH PIT THAT APPEARS TO BE ORIGINAL
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL WATER READINGS ARE FOR 2013--
-44 GPD AND THE SAME FOR 2014
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 WHITE MOSS DR
Property Address
RAB'.EN
Owner Owner's Name
information is MARSTONS MILLS MA 02648 11/5/15
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
SYSTEM APPEARS TO BE ORIGINAL FROM 1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth: LIGHT TO MODERATE
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness LIGHT
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? WOODEN POLE
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING OF TANK FOR MAINTENANCE NOW AND AT LEAST EVERY 3 YRS
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , ' 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 190 WHITE MOSS DR
Property Address
RABEN
Owner Owners Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityj7own State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX WAS VIEWED BY CAMERA
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
GM , 190 WHITE MOSS DR
Property Address
RABEN
Owner Owne's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 600 GALLON
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
PIT WAS OPENED AND WAS EMPTY AT TIME OF INSPECTION WITH NO CLEAR SIGNS OF
FAILURE. CLEAN AGGREGATE WAS VISIBLE IN THE HOLES ON THE LEACH PIT AND THE
BOTTOM OF THE COVER WAS CLEAN AS WELL. THIS APPEARS TO BE THE ORIGINAL PIT
FROM 1987, FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE
DETERMINED FROM THIS REPORT
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 190 WHITE MOSS DR
Proaerty Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
H - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wMt 190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: GREATER THAN 5
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I INSTALLED A SYSTEM AN AN ADJACENT PROPERTY AND THERE WAS NO GROUND
WATER ENCOUNTERED.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 WHITE MOSS DR
Property Address
RABEN
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 11/5/15
every page. Cityrrcwn State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE V
LOCATIONZe i j 7 cI i re .h1 %f �� �, c°� SEWAGE # $F7 ;2 3,
VILLAGE,/h /c F S ASSESSOR'&�,MAP LOTA-0 3''
1�
CANSTALLER'S NAME PHONE NO.��
EPTIC TANK CAPACITY
Qm�LEACHING FACILITY:(type)LeeZA FI`� (size) C c2
NO. OF BEDROOMS PRIVATE WELL OR U IC WA
BUILDER OR O WNER,�QZ z l it l6kti e l�
DATE PERMIT ISSUED: 4—
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No C
F
r r
ii
• t
�r
TOWN OF BARNSTABLE
LOCATIONZef 7 W.hirc- �'1o%f /)t,?reVe W ?
SE AGE # � ,�2 3_�
VILLAGE,,�1 !2� � i�ng /"1 f f f ASSESSOR'S MAP 6: LOT A�0 3 I Pd
INSTALLER'S NAME & PHONE NO. 017rSLyi( spy
O EPTIC TANK CAPACITY
LEACHING FACILITY:(type)Leej f i i (size) 4 eT Ja
ENO. OF BEDROOMS " PRIVATE WELL OR U IC WA
BUILDER OR OWNER�--(2,t e n 6R;e/Z k If Ce.< e.
DATE PERMIT ISSUED: -
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
i an,'J�,
E
3
ASSESSORS MAP NO: -_ 6 �
No.... PARCEL NO.: Fizz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
' ij-" .7
...............J.404W.......OF.......... . I�J& •......I ................
Allpfiration for Dhopoiial 10orkwi Tonstrurtion "pamit
Application is hereby made for a Permit to Construct ( Zr Repair an Individual Sewage Disposal
S t
'on-A s...... .. Lot NojVjS,0,'
........................... ......... ...... .....L
Ow r ress
.. ......................... . ...........56q.6....................................................................
...... 1A
Installer Address
Type of Building Size Lot....2,- ,IL�..Sq. feet
U s....... 3.............................Expansion Attic VIP)
0-4 Dwelling—No. of Bedroom Garbage Grinder
Other—Type of Building ............................ No. of persons........................--.. Showers Cafeteria
Otherfixtures ...............................------------------------------------------- -------------------------------------------------
------------- ........Design Flow............1!��_ ------------------------gallons per person per day. Total daily flow............... ...............gallons.
1:4 Septic Tank—Liquid capacity....IM6jallons 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.
Other Distribution box Dosingnk of
Percolation Test Results Performed by., ..14(�Ve............. ..........
Test Pit No. I......2......minutes per inch Depth of Test Pit.................... epth to ground water........................
(Tq Test Pit No. 2................minutes per inch Depth of Test Pit..........._....__.. Depth to ground water........................
...........7--- -------F ........... ---------**-------------------------*,*-**------*---*.......*-------
.V , 0I.L..............................................................................
0 Description of Soil------.--
........... ........ ... . . ..............................................................
.................... .......... ---------- ... . ............................................................--------------------------------------- -3......T7.- __Cn!1rjL5i..
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
.............................................................................................................. .........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systemin accordance with
the provisions of TL I HE 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........Z.... ---------- ----_-----Da---------------
ate
----------—----
Application Approved By.......... ........................---------------
Date
Application Disapproved for the following reasons:..............................................................................................................
........................................................................................................................................................................................................
Date
12
Permit No.... ... .......................... Issued.......................................................
Date
--———-----------------------—-—---------------------------------
! b
�No....Gst`.7._ Fzs......7..;�..
�. THE COMMONWEALTH OF MASSACHUSETTS
E•
BOARD OF HEALTH ..................... .
Appliration for llisposal Works Tonstrurtion rrrutit
Application is hereby made for a Permit to Construct ( . or Repair ( ) an Individual Sewage Disposal
System t B
cat n Add�e,ss r t o o-•Lot
Ow r Aress
a :,�„. .:_.... I. ..Q...<1 C 4:......................... . ............5��- .................................................................
Installer Address QQ//
Type of Building .,. Size Lot..... :yl.aYI -...Sq. feet
aDwelling—No. of Bedrooms........3..............................Expansion Attic (/ Garbage Grinder (ll�
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures .........--•-••-------------------------------•---------•---.......-•--------------------...............-------•------•-------......-•-•------•-•---•-
W.
Design Flow.............6_?--•-.---•-•-------_---•-gallons per person per day. Total daily flow........... ....__.. gall
ons.
WSeptic Tank—Liquid capacity...._leallons Length................ Width................ Diameter................ Depth................
x 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 ( )
Percolation Test Results Performed by... ,fl#._. .. 4 :. p p�
,.� Test Pit No. I................minutes per inch D th of Test Pit.................... Depth to ground water,._...........•..........
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ....... ...........................•--.......-----------•-----•......-----..............
Description of Soil.......... -
Vw ....-------•---- ............ 3!. -!- Q � - ,� ----- "............------............--------------------
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 MIS 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..
e
� .. ......... .................... ....... Date. ........
Application Approved By----.......
Date
Application Disapproved for the following reasons:..........................................................................................................__..
...-•-----••...................................•--•--•-•----•------•--•-•-•----•------.......------........-•-------------------...-•-------•----........-------•---...................••-•------.---.--
Date
Permit No....4 2.:-:.12..a- ._.... Issued.....................................................
..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t�
.........:....... ......OF..........., ��,, � ......................
l Tatifiratr of Toutplt ttnrr
THIIS JS TO,CERTIFY, That the. 1
Individual Sewage Disposal System constructed ( V) or Repaired ( )
by-----_... t Y r ..-•----. .v�,..�?-1_-�f c -------•----..... ............................................................................. ._...._
f r , Installer
_.
�ias been installed in accordance with the provisions of TITLE 5'of The State Sanitary Code as described in the
application forDisposal Works Construction Permit No...,?.Z:..�.3_:�..
...... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS MNTEE THAT THE
SYSTEM WILL FUNCTION TIS TORY.
DATE............................ J ...-•................................. - Inspector................= ................._... .......-----------•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1
No.. 7.'. +..�. ! ........0F......... P, x " _ .............. Fn.......................
Disposal Works Tonstrurtion rrutit
Permission is hereby granted.._.._.... �'�. _..... .�� l�'�'
to Construct ( or Repair ( ) an Indivldual Sewage Disposal System �~��
at No.....lrl l... 11... S .d.. : .-•-•-- '� .`.?` ... . ::. .. � ' ......°°i .. ::........--
p street. .
as shown on the application for Disposal Works Construction Permit No..�,�:.�a..,�� Dated.......:..................:...............
�r.+� ...-----•-•--........._
of Health J
DATE................................................................................
FORM 1255 A. M. SULKIN. INC.. BOSTON
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LEGEND
EXISTING SPOT ELEVATION 0
PROPOSED SPOT ELEVATION o
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EXISTING CONTOUR ---0- -- ����� MAss90 oF f4'
ROPOSED CONTOUR 0
NOTE THE LOCATION OF ANY UNDERGROUND A. "' - o Floe r�
SEWERAGE WELLS OR OTHER UTILITIES SHOWN ON e c� LEVY X
THIS PLAN IS APPROXIMATE ONLY AS DETERMINED A p No.10050 CD
THIS 4Q a 31341 0
FROM RECORDS AND/OR VERBAL INFORMATION. tR
THE CONTRACTOR IS RESPONSIBLE FOR THE o�Fssl �` �s Afs;s�ER ��@ '� ;
VERIFICATION OF THE EXISTING LOCATIONS IN n s��NAL LA�O
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THE FIELD.
R IS R NINE RiT R AND
_SURVEYOR
E�Y a ELDREDGE ASSOCIATES,INC. CLLENT LOT 1'
ENGINEERS- LANDSCAPE ARCHITECTS JOB NO.
.PLANNERS - LAND SURVEYOR'S �/f�ITE M05SyV,E
DR.:BY= A� IN
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