HomeMy WebLinkAbout0010 MARTHAS WAY - Health 10 Marth`. s Way,West Barnstable
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;
10 Martha's Way 1a
Property Address
Joe Hunt -
Owner Owners N me, t
information is e � Ma 02632 1/12/18
required for every 62Rt2fbii e
page. Cityrrown State Zip Code Date of Inspection
a
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
QCompany Name
35 Content Ln
Company Address
Cotuit MA 02635
Cityrrown State Zip Code
508-364-9587 SI 13522
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 Evaluatio a Local Approving Authority
1/13/18
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information isequired for every Centerville
Ma 02632 1/12/18
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:
System contains al,000 gallon septic tank. As well as a concrete distribution box and a 4x6' leach pit
with T of stone.
4
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound not leakin
g 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
M , 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
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.
El 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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El Z Liquid depth in cesspool is less than 6 below invert or available volume is less
than /z 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
10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. City/Town 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 11 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.
t51ns;3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. Citylrown 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
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Vacant
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 j
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Well
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Forth: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
10 Martha's Way
Property Address
Joe Hunt
Owner. Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. CityrFown 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: Not provided. Recommended
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
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:
Installed 5/20/1990
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Tee's in place at time of inspection
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is Centerville Ma 02632 1/12/18
required for 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
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle 42
11
Distance from bottom of scum to bottom of outlet tee or baffle
" Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping is recommended
a
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
li
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is Centerville Ma 02632 1/12/18
required for 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 Level and at normal level with no signs of back
up
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.): '
i
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
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form --Not for Voluntary Assessments
10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching,pits number:
1
❑ 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 ponding no break out. No signs of failure
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
10 Martha's Way
GSM yy0°.
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
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.):
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.):
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ti 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e 4M 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is Centerville Ma 02632 1/12/18
required for every
page. City/Town 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: 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: 9/6/89
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Test hole data on plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3/13 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
M 10 Martha's Way
Property Address
Joe Hunt
Owner Owner's Name
information is required for every Centerville Ma 02632 1/12/18
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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-- I
j ' Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6115/2000. Inspection forms may not be altered in any way.
Important:
A. Certification �/� 0 G OO 4/-vo,s-
����
When filling out 1. Property Information:
forms on the
computer,use 10 Marthas Way, Centerville, MA 02632
only the tab key Property Address
to move your Bruce Demoranville
cursor-do not Owner's Name
use the return
key. 10 Marthas Way
Owner's Address
&� Centerville MA 02632
City/Town State Zip Code
Date of Inspection: 06/03/06
Date
2. Inspector:
Mike Hudson
Name of Inspector
Septic-wiz Environmental Services
Company Name E
31 Midway Dr
f
Company Address
Centerville MA 02632 '
City/Town State -(:.'Zip Code`''
508-367-5669
Telephone Number j
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ N eds Furthe Evaluation by the Local Approving Authority
06/12/06
In or's Sfg t re 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 origihal 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.
10 Marthas Way-T5 Inspection.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
y` Subsurface Sewage Disposal System Form
A. Certification (cont.)
10 Marthas Way
Property Address
Centerville MA 02632
Cityfrown State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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:
10 Marthas Way-T5 Inspection.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 (cost.)
10 Marthas Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
,1 r B) System Conditionally Passes(cont.):
N 1 A ❑ 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
10 Marthas Way-T5 Inspection.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 (cont.)
10 Marthas Way
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Demoranville 06/03/06 _
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:
10 Marthas Way-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
A. Certification (cont.)
10 Marthas Way
Property Address
Centerville MA 02632
Cityfrown State ZipCode
Demoranville 06/03/06
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:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen Is equal to or less
than b 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.
10 Marthas Way-T5 Inspection.doc•11/2004 Me 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt.)
10 Marthas Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
JA 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.
10 Marthas Way-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
yr Subsurface Sewage Disposal System Form
B. Checklist
10 Marthas Way
Property Address
Centerville MA 02632
Citylrown State Zip Code
Demoranville 06/03/06
Owner's 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?
I
® ❑ 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)]
10 Marthas Way-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
10 Marthas Way
Property Address
Centerville MA 02632
Citylrown State Zip Code
Demoranville 06/03/06
Owner's 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 ears usage N/A-Private well
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
�( Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
10 Marthas Way-T5 Inspection.doc-1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
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.)
10 Marthas Way
Property Address
Centerville MA 02632
City!Town State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: Water Pollution Control/Homeowner-pumped April
2006, November 2003
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity N/A
q ty pumped determined?
Reason for pumping: N/A
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/Altemative 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:
16 years, installed 1990 per homeowner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
10 Marthas Way-T5 Inspection.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
yy< Subsurface Sewage Disposal System Form
C. System Information (cont.)
10 marthas Way
Property Address
r Centerville MA 02632
City/Town State Zip Code
Demoranville 06/03/06
Owners Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2,23'
feet
Material of construction:
❑cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 150+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
pipe in good condition
Septic Tank(locate on site plan):
Depth below grade: 13"feet
Material of construction:
i
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ® No
certificate)
Dimensions: 4'10"Wx8'6"Lx5'8"H - 1000 gallon
Sludge depth: 4'8"(2"thickness)
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness < .25
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? measured stick w/rag, tape,
flashlight
10 Marthas Way-T5 Inspection.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
C. System Information (cont.)
10 Marthas Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Demoranville 06/03/06
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.):
Sytem should be pumped every three years, inlet and outlet tees and baffles in good condition, tank
is structurally sound, all levels normal, no evidence of leakage
Grease Trap(locate on site plan):
n/( 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.):
,t Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
1" Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
10 Marthas Way-T5 Inspection.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 (cont.)
10 Marthas Way
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
,t n Tight or Holding Tank(cont.)
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.):
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even w/outlet, .10
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.):
D-box level, no solids or evidence of leakage in or out
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: - ❑ Yes ❑ No
10 Marthas Way•T5 Inspection.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
Subsurface Sewage Disposal System Form
N
C. System Information (cont.)
10 marthas Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
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:
Type:
® leaching pits number: (1)6'R 3'stone
❑ 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.):
med to loamy sand excellent for leaching, no signs hydraulic failure, ponding, damp soil or
abnormally lush vegetation. 1'effluent depth, stain line 30"+below inlet invert
10 Marthas Way-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 13 of 16
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
SVe�.
C. System Information (cont.)
10 Marthas Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
_l�a Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
P Number and configuration
Depth—top of liquid to inlet invert
r
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:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
10 Marthas Way-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
j Subsurface Sewage Disposal System Form
C. System Information (corn.)
10 Marthas Way
Property Address T
Centerville MA 02632
e ty/Town State Zip Code
Demoranville 06/03/06
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.
!p�
1
�ctukl-e. W611
2 1
O O 1000 Galion H-10
Septic Tank
D-Box
6' Radius Leachpit
w/ 3' stone
OA� Rear of House B
3
10 Marthas Way
Centerville, MA 02632
3 Bedroom
A 1-29.5' B 1-27.25'
2-15' 2-43"
3-29.5' C
C 3-32.5'
TS-Inspection Form.doc•12004 Tito 5 Official ikon Form:Subsurface Sewage Disposal System-
Page 15 of 16
k
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
y` Subsurface Sewage Disposal System Form
C. System Information (cont.)
10 Marthas Way
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Demoranville 06/03/06
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Reviewed as-built
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Review USGS ground water resource map and topographical map
You must describe how you established the high ground water elevation:
Reviewed USGS topographic map for subject property location. Topographic lines indicate property
elevation 20'+above nearest open water elevation.
10 Marthas Way-T5 Inspection.doc-1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System P 9 sP Ys
Page 16 of 16
r -
clyCommonweoM of MossOChusettS
Executive Office of Environmentol Affoirs
Department of
Environmental Protection .
oe�� F.Weld Trudy Core
Argeo Paul Cellueel 8-0-Y
u oorswr David S.stubs
n oann�lariw,.r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CP PART A
. CERTIFICATION �� EI
Peopefty Ad&W& I C3 e ® �1s�a � ®
Address of Owner.
Date of Inspection: '- at different) A U G 8 1997
Name of Inspector. M a-t,e—
CompaoName,Address and Telephone Number. HEALTH DEPT.
VWe__t' M 4_0,:�
/U(Q_L4, �11 TOWN OF BARNSTABLE
CERTIFICATION TA MENT f ��"'
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Vas
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
F
Inspector's Signature: Date: "7_ (y- rl 7
The System Inspector shall nut a copy of this inspection report to the Approving Authority within thirty(30)days of-completing this
inspection. If the system is a shared system or bas a design flow of 10,000 gpd or greater,the inspector and the
the
report to the appropriate regional office of the Department of Environmental Protection. i owner shall submit
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A B, C,or D:
A) OSYV7= ASSES:
I haw not found any information which mdieata that the system violitu any of the bRum aft"as defined in 310 CMIt 15.303.
Any failure criteria not evaluated are indicated below.
81 SYSTEM CONDITIONALLY PASSES:
One or more system components aced to be replaced or repaired. The eystem,upon completion of the replacement or
bo rs> �pass"
pection
Indicate yes,no,or not determined(Y,N,or ND). Describe beau of determination is all instances. If Inot determinW,upl in why act)
The septic tank is metal,cracked,structurally unsound,shows substantial ndiltratwn or a diltrauM:or tank failure u
imminent. The system will pan inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) I
One Winter Street a Boston,Massachussas 02108 a FAX(617)as-1049 a Telephone(617)292-um
40 Premed on R-K"Paper
if
F
P'
I r
4
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART A
CERTIFICATION(continued)
Property Addeeaw
Owner.
Date of Inspection:
Bl SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static ter level observed in the distribution boa is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven a box. The system will pass inspection if(with approval of the Board of
Health):, .
broken pipe( )are replaced _
obstruction removed
distribution boa is levelled or replaced
t
r
The system required pumping more four timed a year due to broken or obstructed pipe(s). The system will pass
-l-g-jinspection if(with approval of the of Health):
•xri '� 4 broken pi (s)are replaced
AM
obstructi n is removed
Cl FURTHER EVALUATION IS REQUIRE E BOARD OF HEALTH:
Conditions exist which require further evalua ion by a Board of Health in order to determine if the system is fa141 to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD F HEALTH DETERMI THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT TH PUBLIC HEALTH AND THE ENVIRONMENT:
Cesspool or privy is within 50 fee of a surface water
Cesspool or privy is within 50 fee of a bordering vegetated wetland or a salt marsh.
3) SYSTEM WILL FAIL UNLESS THE BO OLRD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank as soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 60 feet of'a private water supply well.
The system has a septic tank and soil absorption system and is lass than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indiestas that the well is free
from pollution from that facility and the presence of ammonia nitrogen mad nitrate nitrogen is equal to or lass than 5 ppm.
a) OTHER
(revised 11/03/95) 2
f
r
SUBSURFACE SEWAGE DISSPOSAL SYSTEM INSPECTION FORM
PART A
CEUMCATION(continued)
Property Address:
Owner.
Date of Inspection:
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified bel The Board ofRealth should be contacted to determine what will be necessary to correct the
failure.
Baclrup of sewage into Lenity system nent due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent the muSice of the ground or surface waters due to an.overloaded or clogged SAS or
cesspool
Static liquid level in the distribution above outlet invert due to an overl ed or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" w invert or available vo a is less than 1/2 day flow.
Required pumping more than 4 times in the year NOT tee to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System;,Bess 1 or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is ' ' ,100 f of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or pri is witbk a Zone of a public well.
Any portion of a cesspool privy is within 50 feet c private water supply well.
Any portion of a pool or privy is lees dmn 100 feet greater than 50 feet from a private water supply well with no
acceptable wa quality analysis. If the well has been to be acceptable,attach copy of well water analysis for
coliform be volatile organic compoms,ammonia ' gen and nitrate nitrogen.
El LARGE SYSTEM LS:
The f criteria apply to large systems in adEdion to the criteria a
system serves a facility with a design flow of 301000 gpd or greater(Large system)and the system is a significant threat to public
and safety and the environment because one or more of the following east:
the system is within 400 feet of a surface iriolong water supply
the system is within 200 feet of a try to a surface dSalong water supp,
the system is located in a nitrogen seasiba area(Interim Wellhsad Protection \ (IWPA)or a mapped Zone n of a public
water supply well)
t
The owner or operator of any such system shall bring the s3, and facility into full compliance with the groundwater tsatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the bW regional oboe of the Department fbr h tber information..
(revised 11/03/") 3
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART B
CHECKLIST
Property A&Iress: (6f V l QvliJ
Owner.
Date of Inspection: rf,s If —
nj 1
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
fXone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
_As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
c/
_The site was inspected for signs of breakout.
ZAll system components,excluding the Soil Absorption System, have been looted on the site.
V
The septic tank manholes were uncovered,opened,and the interior of the septic teak was inspected for condition of baffles or
tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
/The size and location of the Soil Absorption System on the site has been determined based on ezistiag information or
}PP���by non-intrusive methods.
,V/The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
. P�
Surface Disposal System.
(revised li/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
f�-- SYSTEM INFORMATION
Property Address: (Q (na,- "-d
Owner.
Date of Iatpection: -7_lee_
FLOW CONDITIONS
USIDENTIA :
Design flow: "373 1pnons
Number of bedrooms:,
Number of amrent residents:
Garbage grinder(yes or no):Ltp
Laundry connected to system(yea or no)"
Sesuonal vac(yes or no): zo
Water meter rwdings,if available:
f
Last date of occupancy:
COMMERCIALANDUSTRIAL:-
'type of establishment:
Design flow: na/da
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yea or no)_
Non♦anitary waste discharged to the Title 5 system- no)_
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe)
Last date of Deco
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as past of inspection: (yes or no)—
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
6--9;tie tanMetrtbution ba/mg absorption system
sin&osaspo,I
Oserflow ossepool
�y
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all aomponeata,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)=vd
(revised 11/03/95) 6
r
T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addreaa: (Q
Owner. 1
Date of Inspection: "7—l l ,
SEPTIC TANkK:
(locate on site plan)
Depth below grader _
Material of construction:C�ooaerete_metal_FRP other(explain)
Dimensions: x
Shdge depth: �- ,, /•
Distance from top of sludge to bottom of outlet tee or baftle:,�
Seam thickness: g 1 !f
Distance from top of scum to top of outlet tee or battle: 3 /,
Distance from bottom of scum to bottom of outlet tee or baffle: �7
Comments:
(raoommeadation for pumping, condition of inlet and outlet tees or Dafnes,de h of liquid leVi Im' Ltion to outlet invert, integrity,
evidence of etc.) aadjee en
GREASE TRAP._
(locate on site plan)
Depth below Material of construgrade:
ction: �Mmetal_FRP_other(esplain)
Dimensions:
S=thielmeaa:
Distance from top ofSwimto top of outlet tee or e:Distance from bottoom to bottom of et tee or baffle:Comsments:
recommendation for ' condition of inlet and outlet tees or battles,depth of liquid level in ae to outlet invert,str�integrity,
evidence of leakage,
(revised .11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
-SYSTEM INFORMATION(continued)
Property Address: (0 M&4W� W&-r `
Owner.
Date of Inspection: 7`t 4(-
7IGHT OR HOLDING TANK_
(torte an site plan)
Depth below(ice:
osnstruction:_concrete_metal_FRP_otber(e:plain)
Dimensions:
Capacity: sallons
Design flow: saIIons/day
Alarm level:
Comments:
(condition of' tee, condition of alarm and float switches,etc.)
—.
DISTRIBUTION BOX
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and •bution is ence of solids carry r,evidence f into or out of box,etc.
PUMP CHAMBER
(locate an ' plan)—
Pumps in worbing arder.(yes or no
Comments:
(note oomdition of pump ,condition of pumps and ap ,etc.)
(revised 11/03/95) 7
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {
PART C
SYSTEM INFORMATION(continued)
Property Address: N'l
Owner.
Date of Inspection: -7— f 4c- 7
SOIL ABSORPTION SYSTEM (SAS)_A
(locate on sae plan,if possible;excavation not required,but may be appraaimated by non-intrusive methods)
If act determined to be present,explain:
Type:
Issehing pits,number:— �-
bsc3ing chambers, number:_
Laehiag galleries,number:
bachiag trenches,number,leagth:
le Ain fields,number, dimensions:
overflow cesspool,number:
C--
C'mrts�condition of soil,,fi�u of h 4c f 'ure, level of ponding, condition of ve n etc.)
(/
CESSPOOLS:_
(locate on site place)
Number and ' !ion:
Depth-top of liquid t invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction.
Indication of groundwater:
inflow(cesspool must be pumped as part of inspect )
Comments: (note condition of soil,signs of hydra 'lure, level of pon ' condition of vegetation,etc.)
PRIVY:_
(locate on site plan)
Materials of Dom:
Depth of so'
Comments: acts condition of soil,signs of hydraulic faihire,.Irml of pmWing,condition of regetadon,etc.)
(revised.11/03/95) 8
T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /0 VJ 9 �tlXG
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
3 - - �?
�k3 q 3
F�
DEPTH TO GROUNDWATER
Depth to groundwater. �b feet
owethod of cletegnination or approximation:
Or
(revised 8/15/95) 9
TOWN OF BARNST�/,�A,�BL22E r�
LOCATION ( -� d�1� ,SEWAGE # V G
VILLAGE ,ph `-1� . ASSESSOR'S MAP LOT
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY ����J �� ��✓' _ ,�!={
LEACHING FACILITY:(type) ���U ��/�ely*7 (size)
NO. OF BEDROOMS 13 PRIVATE WELL OR P BLIC WATE
BUILDER.OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
-512
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ........OF.............................. 57 !cJLe ......................
Appliratiun for Ui,opniial Works Tonsdrudinn rami#
�) Application is hereby m de for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
A, system at: r
It/ �_�_
. ..... ___ .........L. ion ... dress ......
or ................ .. ... ... or Lot No
Owne� Address••.... ? ................................
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
a~ Other—T e of Building --.-_---•----------------- o. of ersons....__....___......_.__..... Showers —
Other—Type g p � ( ) Cafeteria ( )
dOther fi tur �. ._.._.....----•---•------.----•------•----...........................
Design Flow................._(............_.._gallons per pin per day. Total ly flow.._.........�f-.._. ._ ...............ga�lons.
W ff,�
WSeptic Tank—Liquid capacity .. llons Len h Width:`f�� " Diameter................ D th.,S_¢Y..
x Disposal Trench—N - ---------------- -- Width.................... Total Length.__........._� Total leaching area............... sq. ft.
3 Seepage Pit No........�_. ._... Diameter...... Depth below inlet--5,4.3----. Total leachingarea.Z_K(_t ....sq. ft.
Z Other Distribution box ( Dosing tank0-4 )
Percolation Test Results Performed b ..... ._ i4'l4MAJL..........--•---'�..y L. .... Date... - 3
Test Pit No. 1.........�..minutes per inch Depth of Test Pit.................... Depth to ground water.. ....
(s, Test Pit No. 2.....4,_'2,minutes per inch Depth of Test Pit.................... Depth to ground water. ......t GI.......
.....--•-•--•------------•..............................••--.....----••--•---•---•-.......••-•-.........................................................
O Description of Soil:.
W •................................... ..................................................................................................................................................................
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 LI L LZ 5 of the State Sanitary Code—The"�hoard
ed further agrZee of a e he system in
operation until a Certificate of Compliance has been 'ssued by g
,�^
Signed....... ................. ..... `� � ..
Date
Application Approved By. � ..
Date
Application Disapproved for the following reasons:....................................................................................... ........__-
.............••-.._.....•--......---•--...... ......•-•-•-•.._..•--r-..-----.....---......--•--•--•.........----•-••-----•....--•--...--•-•••-•--•-------------•--•-••----.....Date...................
PermitNo..----..�50J ---------------- Issued.......................................................
Date
%
THE COMMONWEALTH OF MASSACHUSETTS
BOA RD', O-F HEALTH
........... ......�OF............................................................... ........................
A#Vftration for lhspoiial Works Tongtrurtwiin Permit
Application.is hereby made for a Permit to Construct (X) or Repair an Individual Sewage Disposal
�OSystem at:
LO/,S> Mil 6 k,4
..................... ........................................ ................................................................
W -Address or Lot No
Location T_
Loc
. ...................... .................
Address IV. I
VY1 JA [�n c.17
...... qck V
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Other fixtures
----- ............[�z...........................................................WW ...
Design Flow.. ...............gallons.
..............._gallons per verson per day. Total daily flow................
7.........V..... f 11 /1 ,
Septic Tank-Liquids capacii ............ty//)a) gallons ' Length.E&f... Width;:Cii ... Diameter................ Depths..
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No .........)............ Diameter...... Depth below inlet...KF...S..... Total leaching .....sq. f t.
Other Distribution box (Y,) Dosing tank
Percolation Test Results Performed by.....Le.kA.IfA iL'If4�...........Z....(............. Date....... ........
e_l .....................
Test Pit No. I.........2...minutesperinch Depth of Test Pit.................... Depth to ground I waterY................� - /
..
'-,Test'Pit No. 2....:4n:Z, ...minlutes per inch Depth of Test Pit.................... Depth to ground water.,.VOM�1.
..............................................................................................................................................................
0 Description of Soil.1-7)11 .......
-------------------------------- ---------------------------- .....................*..........
U ..................................f............. ..................................................................................................................................
......................................................................I.............................. .................................................................................................
U Nature of Repairs or Alterations Answer when applicable..................................................................................................
----------------*".......*-------.......... ------------------ ......... -------------------*....... .......***"*'*---------**......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage�Disposal System in accordance with
the provisions of TLITLZ 5 of the State Sanitary Code— The undersigned further agrees not to-plaoQethe system in
The
oard of health
operation until a Certificate of Compliance has been issued by the �qard of heal,V
A0
............. ...
Signed........... ___---- ..................... ...........
Date
S
Application Approved By.......... , ......
....................................... ...
Date
Application Disapproved for the following reasons:............................................................................................................
......................................................................................................................................................................................................
Date
74 .
PermitNo........0............................................ .............. . ..............u Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f � ,
?............OF.......... ' ..............................
&rtif iratr of Toutplittnrr j
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�<) or Repaired ( )
bY-------------•----•-••------•--•---•-------•---•---•------------------------------------ -------- ------..-..------•-------•---------....-...-------....-.-..-..----•.---------.-------------•-
/) �j J/�/J / � „� Installer ,�t
at........ -�T--- •-•....... :.:....e....---=•,l!U!�:-�-.---------------r._................................................ t .................................................
has been installed in accordance with the provisions ofU,IT I—P j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.____.. �'..?G. ?. dated_... ./.......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION 'SATISFACTORY. ��% '��,��
DATE........... /rUl L
.......... ........................ :: ....... Inspector y--:-----.......---...._...
*.......... ...........m►nsrn..owes.......►•. . ...iy+-w wi.►......... -----------
THE COMMONWEALTH,OF MASSACHUSETTS
BOARD OF HEALTH
�.//A
...........................OF..... ._..........' 'tPn........................._.._............
F No...........7�.�.. FEE. ..........
Disposal Inorkii TonstrWiort rrrmit
Permission is hereby granted...............................................................................................................................................
to Construct (j4) or Repair ( ) an :Individual Sewage Disposal System
at No..------• .K r.T .._._.. /1Y/Z �� r:;P ..---•-t / �`'!
Street %/l ���/�
as shown on the application for Disposal Works Construction
/Permit No..,..__:-•-._-----. Dated..........................................
......-•--•----.......
DATE--------------�....'..-------•-•---�i'.-�......._......................_ "Board of Health
]. now- -
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