HomeMy WebLinkAbout0038 WREN LANE - Health 38 Wren Lane
Marstons Mills
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Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2110/12
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 an the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVI LLE MA 02632
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
2/10/12
Inspector's gnature Date
The system inspector shall submit a copy of this inspection report to the.Approving£Authonty(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared systerm or -n
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit tW
report to the appropriate regional office of the DEP. The original should be sent to to system-owner:>:s
and copies sent to the buyer, if applicable, and the approving authority. P
'"""This report only describes conditions at the time of inspection and under thAonditio"yf use?
at that time. This inspection does not address how the system will perform in the futuarunde7'n
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2110/12
every page. Cityfrown 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:
SYSTEM MEETS MINIMUM PASSING REQUIREMENTS AT THIS TIME ALL COMPONENTS
WERE OPENED ONE PIT HAD @ 10" FROM WATER TO BOTTOM OF INLET INVERT THE
OTHER PIT HAD @ 2.5 FT OF SPACE TO BOTTOM OF INVERT STAINING WAS HARD TO
DETERMINE DUE TO THE DEPTH OF THE PITS, THE STAIN LINE IN THE PIT WITH THE
LOWER WATER LEVEL APPEARED TO BE @18" FROM INLET INVERT DETERMINED WITH A
MIRROR AND LIGHT
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09/08 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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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•09108 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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
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 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'/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage disposal System•Page 4 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 WREN LN
Properly Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
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:
❑ 0 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i.
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage(Disposal System Form -Not for Voluntary Assessments
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate`yes"or"no"as to each of the 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:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/06 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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND 2
LEACH PITS
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2011 134GPD 2010 222 GPD
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CURRENT
p �' Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 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•09/08 Title 5 Official Inspection 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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. Cityrrown 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•09/08 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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is MARSTONS MILLS MA 02648 2/10/12
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
TANK 1979 D-BOX AND PITS 1988 ACCORDING TO PREVIOUS INSP REPORT
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: 2.5
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 GALLON
Sludge depth: VARYING LIGHT TO MODERATE
t5ins-09/08 Tide 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
„ 38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. Cityrrown 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 2
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 101,
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 EVERY 2-3 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•09M 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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage(Disposal System Form -Not for Voluntary Assessments
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0"
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.):
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.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
BOTH PITS WERE OPENED
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology: --
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
BOTH PITS WERE OPENED SEE DETAILS ON PAGE 2
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•09/08 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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. City/Town 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.):
SEE DETAILS PAGE 2
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage:Disposal System: Provide a view of the sewage disposal system, including ties to
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•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
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: SEE ATTACHED PAGES FROM
PREVIOUS PASSED INSP REPORT
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:
SEE PAGES FROM PREVIOUS PASSED INSP REPORT ATTACHED
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09M Title 5 Official Inspection Forth: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
38 WREN LN
Property Address
ELDREDGE
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 2/10/12
every page. Cityfrown 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•09N8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name I Date of Inspection
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. r-G--c -ro sC,4L4E-
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BeaudryT5insp.doc a 11/2004 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
i
• - Commonwealth of Massachusetts
Title 5 ®ffiicial Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
John and Dorothy Beaudry 08/07/05
Owners Name Date of Inspection
Site Exam:
Slope — L..Ev
Surface water — N o E 013 5 ERrV E�
Check cellar — DtZ`{
Shallow wells — N O N C- IN A,rZ.EA C `r- w N w,47ErZ:)
Estimated depth to ground water: `1. 5 -4-
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: No groundwater information on plans of
record for locus and abutters.
® 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:
Bottom of Leaching Pit 8'4" below grade. No groundwater flow into Leaching Pit observed after
pumping. Sump pit in basement dry. Leaching catch basin in street dry; bottom approximately 9.5'
below grade in septic area.
I
BeaudryT5insp.doc^ 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
Commonwealth of Massachusetts
fD
_ Title 5 Official Inspection Form o
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form o
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification a — G,S—
Important: V �3 U�
When filling out 1. Property Information:
forms on the
computer,use 38 Wren Lane, Marston Mills, MA
only the tab key Property Address
to move your John and Dorothy Beaudry
cursor-do not Owner's Name
use the return
key. 38 Wren Lane
Maistons,M Its MA 02648
City/Town State Zip Code
08/07/05 ' C'
Date of Inspection:
Date r
2- Inspector:
Mark Beaudry,PE ,;
Name of Inspector . u
Meridian Associates, Inc.
Company Name
rmm
69 Milk Street, Suite 302 �' r
Company Address
Westborough MA 01581
City/Town State Zip Code
508-871-7030
Telephone Number
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
T-atle 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs wi�
on by the Local Approving Authority
08/07/05
Inspector's Signatu
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. -�
BeaudryT5insp.doc- 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of(Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
A. Certification (cont.)
38 wren Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
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:
BeaudryT5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
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
❑ 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:
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
BeaudryT5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (coot.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
Cityrrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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
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:
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Page 4 of 16
Commonwealth of Massachusetts
®Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
City/Town State ZipCode
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
D)System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: 1_(at time of inspection).
❑ ® 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 coliforrn 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 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.
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Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
A. Certification (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
Cityrrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
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. N 1A
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.
BeaudryT5insp.doc•1112004 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
M SV
Subsurface Sewage Disposal System Form
B. Checklist
38 Wren Lane
Property Address
Marstons Mills NIA 02648
Cityrrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owners Name Date of Inspection
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(3)(b)]
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Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
38 Wren Lane
Property Address
Marstons Mills MA 02648
Cityrrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owners Name Date of Inspection
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
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 80 gpd(ave.)
Sump pump? ® Yes ® No
Last date of occupancy: Current
Date
Commercial/industrial Flow Conditions:
Type of Establishment: N/A
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:
Last date of occupancy/use: Date
Other(describe):
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Page 8 of 16
Commonwealth of Massachusetts
®Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
Cityrrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owners Name Date of Inspection
General Information
Pumping Records:
Source of information: 1000 gal pumped on 6/11/02
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000 from Septic Tank plus 500 from Leach Pit
gallons
How was quantity pumped determined?
Pumper Estimate
Reason for pumping:
Title 5 Inspection
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:
Septic Tank installed in 1979, two Leach Pits and D-Box installed in 1988
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Beaudry-r5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
Citylrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
2.5(36" below top of foundation)
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain): —
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2.5feet
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 ❑ Yes ® No
certificate)
1000 gal (could not be measured,
Dimensions: inlet end of tank not accessible)
Sludge depth:
14"
Distance from top of sludge to bottom of outlet tee or baffle 14"+/
Scum thickness 4" +/-
Distance from top of scum to top of outlet tee or baffle 8'+/
Distance from bottom of scum to bottom of outlet tee or baffle 16"+/-(baffle at outlet)
f
Record Information (inlet end of
How were dimensions determined? tank not accessible)
BeaudryT5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
All components appeared to be in working condition at time of inspection. Inlet end of Septic Tank
was not accessible since located under ground level deck. No infiltration into Septic Tank observed
after pumping. No leakage noted. Liquid level in Septic Tank about 1/4" above outlet invert; lilely
due to minor obstruction in outlet pipe (inlet into D.Box clear).
Grease Trap(locate on site plan):
Depth below grade: N/A
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑'fiberglass ❑ polyethylene ❑ other(explain):
BeaudryT5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (coat.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
Tight or Holding Tarok(cont.)
Dimensions:
N/A
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.):
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0" (liquid level at 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.):
Box appeared level with equal distribution to both Leaching Pits. Liquid level 2" +/-below inlet invert.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
BeaudryT5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Not for Voluntary Assessments
GM
Subsurface Sewage Disposal System Form
Syey`ev
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
Cityrrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
no pump chamber
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of failure or break out. Observed pit contained approximately 33'of liquid. Bottom of pit
8'4" below grade. No groundwater flow into Leaching Pit observed after pumping.
BeaudryT5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
i1M SV y
Subsurface Sewage Disposal System Form
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
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.):
Privy(locate on site plan):
Materials of construction: N/A
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
BeaudryT5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
I'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cost.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
Cityrrown state Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
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. NO--r -ro sC,4L.F-
t,&,brc tlrvG- I.EfK�tK(-
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SeaudryT5insp.doc<11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
I
Commonwealth of Massachusetts
ROOM
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
' M
C. System Information (cont.)
38 Wren Lane
Property Address
Marstons Mills MA 02648
Cityrrown State Zip Code
John and Dorothy Beaudry 08/07/05
Owner's Name Date of Inspection
Site Exam:
Slope — L Fv El_
Surface water — N o N C6
Check cellar
Shallow wells r-►C tN A rLC-A C -ro W N w,4—zE.rz:)
Estimated depth to ground water: 1 . 51 --
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: No groundwater information on plans of
record for locus and abutters.
® 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:
Bottom of Leaching Pit 8'4" below grade. No groundwater flow into Leaching Pit observed after
pumping. Sump pit in basement dry. Leaching catch basin in street dry; bottom approximately 9.5,
below grade in septic area.
BeaudryT5insp.doc 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
va otcl TOWN OF BARNSTABLE.
I-
LOCATION_CA2 SEWAGE #
VILLAGET ASSESSOR'S MAP 6i LOT
INSTALLER'S NAME & PHONE NO. p," ,� Nc�i►I1 /7/dIP- 1
SEPTIC TANK CAPACITY
LEACHING FACII,ITY:(type)--# .0, 0096 A l (Size)��/1G
NO.,OF BEDROOMS_ PRIVATE WELL OR PUBLIC; WATER
e
BUILDER OR OWNER ./D w/ 4 P i v S
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED_
VARIANCE GRANTED: Yes No
C�
No........................ FBB............ .......
THE COMMONWEALTH OF MASSACHUSETTS
O R® OF E L ,�' /�THa '
/�� �Q
® 901.v.OF...... �..1.D � .. /
------
pt�ju inA" AvOratiun for UiipuuFal World C�unstrurtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair (G_1�an Individual Sewage Disposal
System a
le
_- T.... ]e._..._.l....!}1_�`.c5.--6AA----Ae.....----4�T-.......Y t1�.................................. ----•------------
Locati -Address or Lot No.
.. .U�d.e.....He,$. �. . ------------------------- -----------.............
er, 4+ Address
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........... .....Expansion Attic ( ) Garbage Grinder ( )
'PL4-_l Other—T e of Building No. of persons........;Z............... Showers Cafeteria
a' Other fixtures _________________________________
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter________-_____._ Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R'+ •-••---•----•-----------------------•---..........-----••----------........-•-------•----------•-•-..........................................................
0 Description of Soil.........................................................................................................................................................................
w
UNatur of Repairs or Alterations—Answer when icabl ____�'���/4"��___--�!.y---------Ii0_4�8__.��41.............
Agreeent
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions o:'iTLE y g g p y
5 of the State Sanitary Code— The undersigned further agrees not to lace the"s stem in
operation until a Certificate of Compliance has been issued by the board of health. /
Signed----r
-------------- - R&I-1'(�1-�A-`------------JC�_r.°1���
Date
Application Approved BY....I DO,
-✓ ---------------------------------------
•------------•---•...................•----•......Date
Application Disapproved for the following reaso ........................ .....-.--...._ �
---------------------•--------------
.... �/,,,,
Permit No... .0...�.J6.55—-----•------- Issued_...........................................Dau------
D;.te
No..� ......... FEs........ ......_
THE COMMONWEALTH OF MASSACHUSETTS
0 f[® OFAE �H
W......OF.... -�. ..
ApplirFa#ion for Disposal Works Toustrur#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
................_........_...................................................................... ----...-•-•-----•--•----------------------•--..__..........---•-------------------------------•...
Location-Address or Lot No.
----^........•-------_............................•-•-----....--...........................•.... ................................................••-----------------......-----•------------------.
O er tJ ................................Address
Installer Address
d Type of. Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building ............... No. of ersons.....__..................... Showers — Cafeteria
Pa YP g ------------- P ( ) ( )
PaOther fixtures .........................--...........................................................................................................................
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water___________-_----.- -_.
(%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-_-__---_-•-__-_-____-
1:4 -•••-••••-•-----------------••••--•-••--•-•--•••••-•----•--•---•--•••-••......--•---.....-----------•--------------------------------------------------------
Descriptionof Soil `•-•--•------------------------------------------------------------------------------------•--••••--•----•---------
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UNature 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 iI T i.s.
p 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-----------------------------------------•--.....----- --- -----------•......•.
Date
Application Approved By---- 1� - ° _ ....
_ ------•-----------
Date
Application Disapproved for the following reaso :....--••-••-------•--•-•-•-.._..-•-••--•-•-••-•••--•--••---••----•--•••--••-••-••-----•--•-------•._.........--
---••...........-•-•---------•--•----•••.............•----•-• •--•--•--------•--....._._.
Date
PermitNo--- .. L r--------------- Issued.......................................................
�.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF' HEATH
Y...... .....OF.... 0..
.. .. .......... ...
Qlrrtifirtttr of �uut�rfi�aurr
THIS IS TO C RTIFY, That(.V.the Individuo Sewage Disposal System constructed ( ) or Repaired
.. ( }
by................... O ._....10/.'. �e-.f --j-----Instal-----•-•...................................G......---•------------•-----..._..---•-.._..--•-•-
at �. .1_ ! �+-._..K ... ,� C� f -''---1-� IL..[ ----------------------------------------
has been installed in accordance with the provisions of TITZEL 5 of e� Sanitary Code as/descri $i e-
application for Disposal Works Construction Permit No.___ dated_...._._,��,((7 ')- --& .THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... -------------------------------- Inspector........................ ...:......------------------------.-----
THE COMMONWEALTH OF MASSACHUSETTS
D OF
lDB o F R HEALTH
� _.r...................... .
No... ...... FEE......... ...........
Diupos a orks boo tr ion amit
Permission > ere ra ted. h.�l. ._.! ..................................
to Construct ( / I / n IndividI a Sewage /Disp s�.j�y�stem
Street ?'
F 47 /O
as shown on the application for Disposal Works Construction'Permit No.._..__:t -_ _ Dated.._.... : 7___
`DATE................................................................................ Board of Health~\,
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
t o �, TOWN OF BARNSTABLE'
3� z.:Al
LOI.ATICIN C y i9_.e SEWAGE
VILLAGE /tf�,Q r S7da S d / -ASSESSOR'S MAP & LOT 61Ld',!'
INSTALLER'S NAME* PHONE NO. KA,P �l
SEPTIC TANK CAPACITY
LEACHING FACII.,ITY:(type)4 /009<.-l(size) M9d
NO.,OF BEDROOMS_ . PRIVATE WELL OR PUBLIC WATER
a ,
BUILDER OR 0WN5R_ .. /`�wl ��4
DATE PERMIT ISSUED;
DATE COLIPLIANCE ISSUED: 1 f• �f ��
VARIANCE GRANTED: Yes No
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