HomeMy WebLinkAbout0221 SADDLER LANE - Health 221 Saddler Lane
West Barnstable
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information �J
filling out forms I� Sl 1 3 0 0 *�
on the computer,use only the-tab •. Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection.
use the return Company Name
key.
74 Beldan Lane
to r� Company Address
Centerville Ma 02632
City/Town State Zip Code
r 508-658-3456, 774-2484850 SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
5/30/2019
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
A
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
N
Commonwealth of Massachusetts
{ Title 5 Official Inspection Form
fn Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 221 Saddler Lane West Barnstable is served by a Title V septic system
consisting of a 1500 gallon septic tank, distribution box and 3 500 gallon leaching chambers.
The system was found to be in proper working condition at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
-7
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The systern required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface i -
ubsu ace Sewage Disposal osal System Form Not for Voluntary Assessments
9 p Y rY
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for everyWest Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
El ID this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑, Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 444 gpd
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1T a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!/ 221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Tank pumped after inspection
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? size of tank
Reason for pumping:
routine maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
ti Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information i;
required for..very West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. . Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
system installed 5/12/2006
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1
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.):
Joints ok, no leaks or blockages. Vented through roof
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
U Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information its required for every West Barnstable Ma 02668 5/30/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 811
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:
1500 gallons
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2°
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was cleaned for inspection and should be done again every 2 years for proper maintenance.
Tank was structurally sound and not leaking.
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 110 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
J 221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc-rev.'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
j. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for:every West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. . Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Distribution box was level and in good condition with no rot. Water level was even with outlet invert
with no signs of past backup.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection- Form
1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3x500 gals
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.'7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, e:c.):
Leaching facility consists of 3 500 gallon leaching chambers with 4' stone surrounding. Leaching
facility was found with 1' standing water and no stain lines higher.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top cf liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions cf cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for everyWest Barnstable Ma 02668 5/30/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for eery West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-ske`ch in the area below
❑ drawing attached separately
✓tZ I� Cb Z o
g2 Z7 6
,33 39 G
3y 5"�5
IK 33
83 r `11
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
(t� Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
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: 3/14/2006
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:
Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
221 Saddler Lane
Property Address
David Nunheimer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/30/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
t•
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TOWN OF BARNSTABLE
LOCATION O�Q e -'i/S.'EWAG5#
VILLA GE SSOR'S MAP&LOT
NAME&PHONE N ryd l0 4o
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS.
BUILDER O
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 76Z Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 30000�feet of leaching facility) j� Feet
Furnished by s�X'' -l � tic_ ?. �i IC. C�'tf�3—, ���
,
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COMMONWEALTH OF MASSACHUSE17S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
UEC 2 2003
TO"N OF BARNSTABLE
TITLES HEALTH DEBT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 221 Saddler Lane OPIP
W_ RarnGtahlP ARCEL ,
Owner's Name: Ren G„rrn
Owner's Address: LOT : 32„
Date of Inspection: I/— /7" G 3
Name of Inspector:(please print) W i 1 1 i am F_ • Robi nson sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
I certify that 1 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.1 am a DEP
approved system inspector pursuant
�to Section 15.340 of Title 5(310 CMR 15.000). The system:
(/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �� Date: < CJ 3
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.
Notes and Comments
****This report only describes conditions at the time of inspection and u der the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
r
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 221 Saddler Lane
_W_ Barnstable
Owner: Ren Surrn
Date of Inspections
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys cm 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:
System Conditionally Passes:
One or more system components as described in the"Conditional Pass,'section need to be replaced or
rep ired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans er yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please
expla 1.
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsoun ,exhibits.substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existin tank is replaced with a complying septic tank as approved by the Board of Health.
•A me 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicati VV g that the tank is less than 20 years old is available.
i
ND explain:
i bservation 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 ystem required pumping more than 4 thnes a year due to broken or obstrneted pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced 3_;
obstruction is m wvcd
ND explain
Page 3 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i
PART A
CERTIFICATION(continued)
Property Address:_ 221 Saddler Lan
W. Barnstable
Owner: Ben Surro
Date of Inspection:
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 tailing
iling to protect public health,safety or the environment.
System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone I 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 front 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:
I
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 221 Saddler Lane
W. Barnstable
Owner: Ben Surro
Date of Inspection: U.2
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 I 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 Let from a private uata
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free.from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.l
(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.
j9d.
arge Systems:
considered a large system the system must serve a faci!ity with a design flow of 10,000 gpd to 15,000
must indicate either"yes"or"no"to each of the following:
following criteria apply to large systems in addition to the criteria above)
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—1WPA)or a mapped
Zone 11 of a public water supply well
if yo have answered"yes"to any question in Section E du: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
signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. he system owner should contact the appropriate regional office of the Department.
4
Page S of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 221 Saddlery Lane
W. Barnstable
Owner: Ben Surro
Date of Inspection: ZI— !1—G 3
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No/
i .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 baffl s or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes .no/
i/ 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)J
5
y
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 221 Saddl Pr T,anP
W- Barnst-ahlP
Owner• B n Surrn
Date of inspection:.41 17—0 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):-3 Number of bedrooms(actual):_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 0 of bedrooms): 3 3 S'
Number of current residents: iti b
Does residence have a garbage gander(yes or no):11-b
Is laundry on a separate sewage system(yes or no):%L O [if yes separate inspection required]
Laundry system inspected(yes or no): /t,, v
Seasonal use:(yes or no):�U
Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 2 : 1 6 0, 0 0 0
Sump pump(yes or no):/ 2 0 01 : 200,000
Last date of occupancy: v N
CO
MME IAL/INDUSTRIAL
Type of esta lishment:
Design flow based on 310 CM 15.203): gpd
Basis of desi flow(seats/persons/sgft,etc.):
Grease trap resent(yes or no):_
Industrial wg ste holding tank present(yes or no):_
Non-sani waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of ccupancy/use:
OTHER( escribe):
GENERAL INFORMATION
Pumping Records
Source of information: )RG. (�
Was system pumped as part of the inspection(yes or no):�d
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping: nv 1;i v < <I s
TYPE OF SYSTEM
_ OF
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:
Were sewage odors detected when arriving at the site(yes or no):dV v
6
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Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 Saddler Lane
W. Barnstable
Owner: BPn Su.rro
Date of Inspection:
BUILD SEWER(locate on site plan)
Depth bel w grade:
Materials of construction:_cast iron —40 PVC_other(explain):
Distance from private water supply well or suction line:
Comme is(on condition of-joints,venting,evidence of leakage,etc.):
SEPTIC TANK:2(locate on site plan)
Depth below grade: 1 /
Material of construction: z concrete metal
lain -- —fiberglass—Polyethylene
_other(ex
P )
If tank is metal list age:— Is age confirmed-by med•by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) ! ► + I
Dimensions: a L
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: a
Scum thickness: W "
Distance from top of scum to top of outlet tee or baffle: 41 I
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: d � 9 C U v C;Z 3
Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
L
SE TRAP:_(locate on site plan)
Blow grade:—
I of construction:_concrete metal fiberglass polyethylene—other
): — —
s ons:ickness:a from top of scum to top of outlet tee or baffle:
a from bottom of scum to bottom.of outlet tee or baffle:
last pumping:ents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
led to outlet invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 Saddler Lane
W Rarncttah1 P {+
Owner: Ron Cnrrn
Date of Inspection:
TIGIIT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth be ow grade:
Material f construction: concrete metal fiberglass_polyethylene other(explain):
Dimension
Capacity: allons
Design Flo gallons/day
Alarm pres nt(yes or no):
Alarm Icve : Alarm in working order(yes or no):
Date of las pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4'
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 cs or no):
Alarms in working order i yes or no):
Comments(note condilioi i of pump chamber,condition of pumps and appurtenances,etc.):
8
' Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .221 Saddler Lane
W. Barnstable
Owner: Ben SLrr0
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation"not required)
If SAS not located explain why:
Type
leaching pits,number:_
eaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
G�mmcnts(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
et..): 3 K
L 4. 4Sl
1 �
CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and confi uration:
Depth—top of liqu to inlet invert:
Depth of solids laye :
Depth of scum layer
Dimensions of cessp ol:
Materials of constru ion:
Indication of groundi vater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (loca on site plan)
Materials of cons tion:
Dimensions:
Depth of solids:
Comments(note c ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 Saddler Lane
W. Barnstable
owner: Ben Surro
Date of Inspection: -3
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.
/y
m
l
1
J
10
f .
Page:11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 SAddler Lane
W. Barnstable
Owner. Ben SLrro
Date of Inspection: `t U 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells ,�
Estimated depth to ground water_.2 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Il
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
� C
w
re
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner's Name: JAMES PICCIOTTO
Owner's Address: 51 EAGLESTONE WAY,COTUIT,MA.02635
Date of Inspection: 10/1/01 �jr a— �
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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:
f;x
X Passes ,
_ Conditionally Passes ;
_ Needs Fu Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 10/1/01
The system inspector shall subm' 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
j
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments ,
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM USEFUL
LIFE. RECOMMEND RAISING ALL,COVERS.
****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.
t;
t
TitiF 5 IncnPrtinn Fnrm A/1 V100 1 1
.Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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 PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM
USEFUL LIFE.RECOMMEND RAISING ALL COVERS.
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.
n/a 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: n/a
n/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: n/a
n/a 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: n/a
r
Page 3 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued,
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
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
c will rot i ect public healt
h,th safety p p y and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system
y p rp y em(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 n/a
"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:
n/a
Z
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
'Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02665
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or.privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large 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.
You must indicate either"yes"or"no".to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet.of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any'question in Section E the system is considered a significant threat,or answered
"yes".in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
Check if the following have been done.You must indicate "yes"or"no"as to each of the following:
Yes No
t
X _ Pumping information wa`s provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems'?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CM 15.302(3)(b)]
j
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:2
Does residence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a 3
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,gattach previous inspection records,if any) F
_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): n/a
Approximate age of all components,date installed(if known)and source of information:
1986 AS BUILT
Were sewage odors detected when arriving at the site(yes or no): NO
i
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
BUILDING SEWER(locate on site plan)
Depth below grade: 42"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:36"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THESEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFUL LIFE ELECTRICAL LINE RUNS OVER COVER.RECOMMEND RAISING COVERS..
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity; liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
�6
r1
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
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): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING
PROPERLY.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why: .
n/a
Type
n/a leaching pits, number: n/a
FLOW DIFFUSERS leaching chambers, number: 1
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.):
FLOW DIFFUSER APPEARS TO BE FUNCTIONING NORMALLY,BOTTOM AT 6' -SYSTEM SHOWS NO
SIGNS OF FAILURE.
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: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
-Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
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.
IA
C
❑ ;B o
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At '3 L
k lS
Ab a<
6D
in
-Page 11 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 221 SADDLER LANE WEST BARNSTABLE,MA 02668
Owner: JAMES PICCIOTTO
Date of Inspection: 10/1/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water.12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
YES Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER INFORMATION FROM ENGINEERED PLANS- 12+
G01
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!r
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' BORTOLOTTI CONSTRUCTION, INC. �oy� 1
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 0, Q ,
508-771-9399 508428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART A Z
R r '',,`c c•�Y r,;.=.'; 3 , w ;.<: r CERTIFICATION
Property Address.
Date.of Inspection: (A�j Inspector's Name:
'.'.Owner's Name d.Address:
s�. fi:r
44.trid.#
CERTIFICATION STATEMENT* �s
I certify,4that I-have personally.inspected'the sewage disposal system at this address and that the informa-
tion reported belowl,is true,�accurate and complete as of the time of inspection. The inspection was per-
formed b on my_training'and.experiencein the proper function and maintenance of on-site sewage
disposal . stems. The System:
Conditionally,Passe
Needs Further:E ation' a Local Aproving Authority
�i Fails kF
Inspector's Signature: Date: CX&lei
The System Inspector shall submit a copy of,this inspection(report to the Approving authority within thir-
ty(30)f4ayssof completing this inspection.;If;the system is a shared system or has a.desip flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate(reg*onal.,
officep4he Department of Environmental Protection. The original should be sent to the sy ? /�?
and copies sent to the buyer,.if applicable and the approving authority.
40
INSPECTION JMMARY �+
A)SYSTI PASSES r f
I have not found any information which indicates that the system'violates any ofcriteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are i
. }•�r"L � '.4: r s:. a, r+j£; a ''!°} . ty:-. - . ,2 fib''
B)SYSTEM CONDITIONALLY PASSES; '
ka • One,or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND)..Describe basis of determination in all instances. If
"not determined%explain why,not:
The septic tank is metal,crgckgd,stntcturally unsound, shows substantial infiltration or
i, q,--ar Y.1,p iltration,.or tank failure is'imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
� ;Sewage;backkup>or,+.breakout or high static water.level observed in the distribution box is due.
` to broken or obstructed pipe(s)or due.to a broken,settled or uneven distribution box. The
;- system will pass inspection if(with approval of The Board of Health):
I
4
j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
a `' "'F=' CERTIFICATION(continued)
Broken pipe(s)replaced
f e $6�' '4'Obstruction is removed
Distribution Box is levelled or replaced
f.f The System required pumping more than four 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
iµs .3j
r °Qbstructip, is removed,
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 the public health,safety and'the environment k +
wsi}iSYSTEM:WILL'PASS UNLESS BOARD OF HEALTH'DETERMINES=THAT THE'
SYSTEM.3S NOT FUNCTIONING IN A MANNERWHICH 4WILL PROTECT'THE s
+ PUBLIC HEALTHAND.=SAFETY`AND THE ENVIRONMENT , "
Cesspool.or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. .._
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH JAND'PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES;THAT THE SYSTEM ISYUNCTION-
ING INA.MANNER THAT PROTECT THE PUBLIC.HEALTH AND SAFETY AND THE
„ENVWNMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface,
water,,supply or.tributary to a surface water supply. :` '' �? XP..t.
*f fm", Mile,� 4 iThe�system has a septic tank and soil absorption system and is with 'Zone I of a public
Nit "water supply=well. :�.,.
6,40r� sr=s .,;;.The system..has°a septic tank and soil4bsorption.system'and is within 50 Feet of a private'
water supply well. rt7+
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a welt'water analysis for'coliform l
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence-of ammonia nitrogen and nitrate nitrogen is equal,to or less
,6
r�00i �
1D)SYSTEM FAIIS: {; , °
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 below. The.Board of Health
should be contacted to determine what will be necessary to correct the failure`
,�Backup�of sewage into facility or system component due Wan overloaded'or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an.
i ,} h=tipvro 14:: overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to`an overloaded or clog-
.
z�Liquiddepth intcesspool is less than 6"below invert or available volume*is less than 1/2
i.•;day,`flow
_Required pumping more than 4 times in the last year NOT due to clogged or obstructed
r, pipes) Number of times puinped
41- t -_2 1, ,
.. �.'
r
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a 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 I 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. If the well has been analyzed
to be acceptable,'attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FA,LS:
The,followmg,criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following'
conditions exist:
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.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
`"Check4f the following have been done: '
Pumping information was requested of the owner,occupant,and Board of Health.'^
✓None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
trodu ed 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.
EThehT a facility or dwelling was inspected for signs of sewage back-up.
system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
' Ail system components,excluding the Soil Absorption System;have been located on site.
_ The septic tank manholes wefe uncovered,opened,and the'interior of the septic tank was in-
spected for condition`of baffles or tees,material of construction,dimensions,.depth of liquid,
/Thedepth of sludge,depth of scum,size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3- f
Y t V°
v
Y I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
Fkzc. -r/The facility owner(and occupants,if different from owner)were provided with information on
the'proper maintenance of Subsurface Disposal System
F. SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
t3..r1,k a q t r s ,.ii. , •{� � t1=, FLOW CONDITIONS
D Iy
Design Flow: allons:,Number of Bedrooms: Nutpbcr of Current Residents:
Garbage Grinder: Laundry Connected To System: Seasonal Use:
ap .Water,MeteuReadings,rif 'I ble: C/
Last Date of_Occupancy:
COM VIRR AI IINDL1STRi_AI ; .. " 0
Type , e . ,<
of Establishment.
Design Flow;_ lons/day:.t,Grease,Trap-Present: (yes or.no)
Industrial Waste Holding Tank Present:
�e Non ta Docharged.Tq The Title V.System:
r` Water.Meter Readings,If.Available. Last Date of Occupancy:
OTHER.-.Describe)
Last Date of Occupancy:
...,'GENERAL INFORMATION
PUMPING RECORDS and-source of:information:
System Pumped as part of inspection: C) If yes,volume pum ons
Reason,for pumping
TYPE SSYSTEM: , f
LL,t ,, tic?Tank[Distr►bution Box/Soil Absorption System
Single Cesspool
Overtlow;Cesspool
Privy R
Shared System(If yes,,attach previous inspection records,if any)
Other(explain).
r .
'41? MATE 9 of ap.,compdnents,date installed(it known)and source`of,information:.
ZIF -. .
Sew a odors detected when arriving at the site:
-4-
�a�� + '' v d+• �1iA�a�����4� rid sti t r�:t .' � � .y � " f ( -
a. -'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below.grade: Material of Construction. concrete metal FRP_Other
(explain)
Dimisions:_ Sludge Depth: Scum Thigkness:
Distance from top of sludge to bottom of outlet tee or baffle:
.J
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments,: (recommendation pumping,.condition of inlet and outlet tees or baffles,de th"of liquid
1 1 in lation to outlet invert, structural integrity,evidence of leakage,etc.)
GREASE TRAP:.''
Depth Below Grade: Material of Constnuction: concrete metal FRP Other +
(explain) — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquidi ;
level in relation to outlet invert,,strnctural integrity,evidence of leakage,etc.)
♦ p i
TIGHT'OR HOLDING'TANK:—A,k1
Depth Below Grade: Material of Construction:__concrete_metal—FRP—Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of'inlet tee, condition,ofalarm and float switches, etc.)
a,
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments: (note if evel_and distribution is equ evider a of solids carryover,evidence�fleakage into
0 out of box,etc.)
PUMP CHAMBER:
Pump is itr working order:
Comments:(note condition of pump chamber, condition of pumps and appurtenances,etc'.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
a }`Teaching pits;number:'•` Leaching chambers,number:,Leaching galleries,number
t {�
1 � .;..Leaching trenches;number,length
Leaching fields;number,dimensions:
A�;<'Overflow cesspool,"number:
Comments:.(note condition of soil,sign of h draulic failure lev I of ponding,condition of vegetation,
c.)
01
CESSPOOLS:jv. ,
Number and configuration: Depth-top of liquid to inlet invert: -
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: ,
.Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
• PIKIVY:� . •,
Materials of construction: Dimensions:
Depth.of.Solids:
Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
�t
-6-
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (conlinucd)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include des to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
o�
10
,(P .i•(�
3�
` 4
. I
DEPTH TO GROUNDWATER: i
Depth to groundwater:_ Z/ Feet
Method of Determination or proxi ation: /� I'� p� i'�'r�! 1/'5 r
AP
7-
T '
I
/9 3/
_ CIM
BORTOLOTTI CONSTRUCTION,INC. 1 8 1996
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508-428-8926 FAX: 508-428-9399
hULTHO pr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F
PART A
CERTIFICATION --�'`
Property Address: 02 /�,.- �Q
Date of Inspection: 3/ - Inspector's Name: 04240,2
Owner's� Name and..ddress: t /-�
CERTIFICATION STAT N-
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was.per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal 5ystems. The System:
Passes
Conditionally Passes
Needs Further Ev tion By,4he Local Aproving Authority
Fails
Inspector's Signature: Date: -7 1g&
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer,if applicable and the approving authority.
INSPECTIONSUMMARY:
A)SYS PASSES:
I have not found any information ,which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If
not determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
-1-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four 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
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 the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and 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 with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within.50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than analysis
Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)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 below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume,is less than 1/2
day flow.
Required pumping more than 4 times in the last year 1YS2T due to clogged or obstructed
pipe(s). Number of times pumped
-2-
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater.
elevation.
Any portion of a 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 I 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. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
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.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast 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.
,!:LThe system does not receive non-sanitary or industrial waste flow.
eThe site was inspected for signs of breakout.
v' All system components,excluding the Soil Absorption System,have been located on site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees,material of construction,dimensions,-depth of liquid,
depth of sludge,depth of scum.
l�The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
'I
i
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM llV.SPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION '
FLOW CONDITIONS
RESIDENTI ,�
Design Flow: O allons Number of Bedrooms: Number of Current Residents:4An_P,
Garbage Grinder: Laundry Connected To System: t°S Seasonal Use: ? ,4
Water Meter Readings,if availabl
Last Date of Occupancy: 9•�9
COMM .RCLALANDUSTRiAi
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial.Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: /�/�U('r' �oSPE'r)
System Pumped as part of inspection: If yes,volume pumped: gallons
Reason for pumping:
TYPE SYSTEM:
V Sepdc Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
APPROXIMATE AGE of all co pone ts,date installed(if known)and source of information.'
`9 i /mac '
Sewage odors detected when arriving at the site: d
-4-
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material'of Construction: V- concrete metal FRP_Other
(explain)
Dimisions:`d,5')(b'k S Sludge Depth: �j Scum Thickness: /1 O 12 e-
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relationAp outlet invert,structural integn ,evidence of le aka e,etc.)
cv
GREASE TRAP:
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain);
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK::
Depth Below Grade: Material of Construction:—concrete—metal—FRP Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:Ja � 4nQ k c
Comments: (note if level and distribution is equal,eviddhce of solids carryover,evidence of leakage into
or out of box,etc. I / ism`,[sir Vito'—,A-IV �JQS Ca o� -}��,�.y �i�c C'/Q A
PUMP CHAMBER: ,
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil, si ns of hydraulic failure level of ponding,condition of vegetation,
etc.) VA 6 ff
0lfeLl
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soitk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVYA6
Materials of construction: , Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6-
I•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
0,z 6.1.
S�
,
0
DEPTH TO GROUNDWATER:
Depth to groundwater: 4 Z Feet
Method of Dete 'nation or Approximation: �i` ��,�i h?l'rr ` ✓O ell,S
-7-
f. Cr
No...��........G....... FEs.....��....�.�—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF HEALTH
.To.W.N.................oF..............13.A.. N ......................................
Appliratiou for Di.ipnuttl Vorkg Toustrur#inn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
LE.p — L N'_ W ST ' fig S t 13
..........4 1. ......5_ 3....�72. lz.._.. 4 .._ N.. . ..................
Location Address t or Lot No.
.1...1.:C�.! lS. ... ................ !.. .._ +h�l!_� --------------- ------------
....•.... tt
' •� �O �Addrese�/
w ✓ f/
Installer Address
UType of Building Size Lot...111.Q:z,5.....Sq. feet
U Dwelling—No.` of Bedrooms.......... -•. ........................:.Expansion Attic' ( ) Garbage Grinder ( )
Other—Type of Building •. Showers — Cafeteria
P4 yP g .......::......•--••-------: No. of persons..........------:....----- ( ) ( )
W Other fixtures ...:.....................................................
.......
d ;
Design Flow---.........)j.U.........................gallons per person er day. Total daily flow.._.._.3_3 d-.......................gallons.
w 4 /
WFlo pftc� j nk—Liquid capa8tyJQ0,6..gallons Length.._ ..�9..... Width:.-._+ aQ . Diameter=.- Depth...... ...
x 1 �i—No. .....�............. Width...,(?........... Total Length...::.�_:4---.---- Total leaching area_...Z�?_O sq. ft.
3 Seepage Pit No..... ............ Diameter.................... ept below inlet....Z_.......... Total leaching area...........:......sq. ft.
z Other Distribution box (c-f Dosing tank
Percolation Test Results .Performed by..?. � L U...... Date........ ...........
a Test Pit No. I................minutes per inch Depth of Test Pit..... Depth to ground water-_.1J�.l .�c..-..
(� Test- Pit No. 2.....�..Z'niinutes per inch Depth of Test it..... Depth to ground water._- ._o!�?L.....
O Description of Soil.�:#t .l..�:.. .`..":Z4"._ l ?.i'_. .ss,34t?_1.?-,:.
v .`, 9��-.L 2�� .: I P:Sr� ! ....lq ... :1l� S...C.U.C.S.A51[a_n.1.��.:.�4.c :�A
.. !'+M_.r.,1. ��.`. .�.��..�.1� Q.IL. . ��.`..- v= C4i�AR...�. i?....s WLD
(—t1 5 tj�- L �
U .rairss-o>-Akeratierts---�lnskve-riea applicable--- 8 ..."
oE..�1Ua....----••-•......................:.........................••----...................-•--------- •-------••-----•- •-----......-•--••--
Agreement: -
The. tindersigned agrees to install the aforedescribed Individ 1 Sewage Disposal System in accordance with
the provisions of L I':L; 5 of the State Sanitary C The,un- si d further agrees not to place the system in
operation until a Certificate of Compliance has be y oa iealth.
Q✓ 1,� Signed. L --ZKa
�
Application Approved By:........•-•-•-•............................................•---•--.....•--•-•....•••-••••-•----• ........................................
..........
Date
Application Disapproved for the following reasons:.............•--•--...............-•-------.............__.........--•--...............•........=...........--
..................................••---•......•--- _....-•---...... •-•......------.................--•-.._..........--•------•---•............................................................
Date
PermitNo................•---••---•--............................ Issued........................................._.............
Date
FEs..........................
r~ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
"To.ON N.................O OF..............T3�I R hi_STA_�L.�' .........-....._-.........
Appliration for Biipuual nrks.4-unutrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
1 U "_i 4 .�.......' 4:t"3 J; : -ill C �l�>T -16- F� S / �LF
....... — /— Location Address ..- or Lot No.• •............................
......... 13 1:..�.... �! 1 /..1.�•1 ................. ............. ....•---.. . .. `�, �.!_,.r� � .
W � Or / � dress-1 A /
,., ... ..................:.. .. .� 7. .,... ........................._.....
Installer Address
Type of Building Size Lot....I :.8.�:5.....Sq. feet
r—r Dwelling—No,"of Bedrooms...........Z..............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............... No. -of ersons......___............_.._._. Showers
a YP g P ( ) — Cafeteria ( )
QOther fixtures -----•--•...............•-----.._...----•---••-•--••---•----------......--------•--•--•-•-............••--•-••----•........_......•--•...-•-•------•-
W Design Flow............!!.fl.........................gallons per person per day. Total daily flow.......:�_�f.)......................_gallons.
r N U r r.
GG Septic, ank—Liquid',capacity.1.06,41-.gallons Length..._..6_1_.. Width:..'f0... Diameter..-...._..... Depth..:,---..
floD>isposal�"reic-h—No. .................... Width...!U...._...... Total Length.__LJA....... Total leaching area:__ ft.
3 Seepage Pit No.....:*------------ Diameter.................... Dept i below inlet.._.z............ Total leaching area..................sq. ft.
Z Other Distribution box (cj Dosing tank ( )
aPercolation Test Results Performed by...Q.4? !��1 l�' .aPJ.10 !J aQN.(M...... Date..... .' .:.$.ram......_....
..a Test Pit No. I................minutes per inch Depth of Test Pit.... 3,Z��=__ Depth to ground water...
tr. Test Pit No. 2......e Z'nunutes per inch Depth of Test git..... Depth to ground water-_1�Q n).f......
---•..........................................................•-------•-
O Description of Soil. :.+.a.!_w..�.. '."_2 Q ??.r..;.S_ 3 � i z ...? `.".. . �.... r .!E r1 L n1 rl J
4.".- a_ °_..Nt .a._sAS!1.D Sul itit S-•�t��C.t4 lc�! A.4�_.t.u.M.►'A:�:T 1 5....b ..F1� SA►vt�)
U Natur-e:of Repair-s-or�Alter-ations•—Answet�whem-appl2able.....1 .()'�...._���. '`....7 l.C?•rt? - S A►�1 A tJ/ I i
........ ...0...................
Agreement:
The undersigned agrees to install.,the aforedescribed Individ 1 Sewage Disposal System in accordance with
the provisions of TI'U- ' 5 of-the State Sanitary C 11, "I'he un si d further agrees not to place the system in
operation until a Certificate of Compliance has be i y oa �' icalth.'
jr Signed. �'.f.. ......... ............................................... ... ..........� .........
.:+t. / ate
ApplicationApproved By.................................................................................................. .....................................
Date
Application Disapproved for the following reasons:.................................................................................................................
......_....•...........................................•----••-•---..................--•--......•....._......:-..----•--•------•----------=•-----........-----•-•--.....---•----................---......
+ Date
Permit No:........................•- Issued.....••-•-----
... ...................... Date r ----.. .......
.... ......... .... ............... .........». ........_.. .............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR4 OF HEALTIIJ t
OF'. .. .•• .............................................
(Irrtif irate of Gamplittnrr
THI S TO C RTIFY, T the Individual Sewage Disposal System constructed ) or!Repaired ( )
_
at... ( � = .. -_ i.._ t .:. ._. .......................................•-••-...
---
-
has been.installed in actor ante with.the provisions of TITLE, j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION• N SATISFACTORY.
DATE. .......
........��::�,:%�1...s�S.:Q. ............................ Inspector - 2=•---e -I� .- •------ ------.-....---------.........
.�.....".a....-,.................• -,... ,..,>...... .. ... ....
------------
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD HEALTH
.............:................;Ot=.....-...
No... .71-........... f` F JCS
Mop or a Tono o n ermit
.c .
.............................................Permission is hepel�granted._.
to Construct �o�repair_( i' Ivi ual S a e Disposal S}
••- A
,�!� Street/ ,�•
as shown on the pplication for Dlsposal Vl'orl:s Constructio^'n Permrt��No. _ .......�,�Dated..__--__ _ ..................5......
�r t.
#� /ll � �_ ---�:e ••.. tBoard 4of-Health--�
DATE.. .: : :--------------•--------- ----- r' t t
}
I
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TEST BY Pdl^l " (/f
WITNESS
TEST GATE BEDROOM HOUSE
DESIGN LOT 20 3o n 14 �pv
T.N. tr 1 T.H. a 2 q,
n ..W ELEV.1�0.21�q ELEV."IS�� NO
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a SDI M ? REQ'D.SEPTIC TANK SIZEMW
MAR 5 {�l� �20tt ' LEACH FACIL TY
F I ry E Q�,I tilb L SIDE WAL I�Fx 2+I D,�L��l/0�0�2 G 1 ,O G/D. : ` -
GoM �dLl.g '11 }� Sa-I�IC� BOTTOM JO) (s�D,0.���0 ►.- G/D: �-
trzIt ofFi ti ,af-�D) 51 0� TOTAL
USE: Ott✓ f✓LOJ,►l..• Jkl% IS90K k� �T!-�- I�'�, I --
< I \
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- -WATER ENCOUNTERED -
�l
NOTES: (UNLESS OTHERWISE NOTED)
1.DATUM(MSL) TAKEN FROM h� µ D�-_I G I}- QUAORANGLE MAP
2:MUNICIPALWATER_ l� AVAILABLE
3.PIPE PITCH:WN PER FOOT
4.DESIGN LOADING FOR ALL PRE CAST UNITS:AASHO• -44 l�K Of
S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. P� 9rt �E C71�G'r�Q}� O
S.PIPE JOINTS-SHALL BE MADE WATERTIGHT ® A^I fr }{; 1, I I
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. �; + — -7, SITE STATE ENVIRONMENTAL CODE TITLES — PLAN
1 _A
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_ CIVIL ENGINEERS. LA119
- . . ---BOARD OF HEALTH - - _.-- - .. _ _ _ .
LAND SURVEYORS "
,p .•. REG R
(EXISTING)............. .` �iBO RD OF HEAL£-
SU VEY � III ,In�
CONTOURS (PROPOSED)
APPROVED DATE MA fi Y���.0 SCALE
_. DATE 2
1
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