HomeMy WebLinkAbout0016 COLONIAL FARM CIRCLE - Health 16 Colonial Farm Circle, Marstons Mills
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Commonwealth of Massachusetts oqf-009 00(c
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owners Name /
information is
required for every Marstons Mills A Ma 02648 6/19/20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer, Michael DiBuono
use only the tab
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Ln
,Q Company Address
Cotuit Ma 02635
Cityrrown State Zip Code
508-364-9587 S113522
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 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
7/15/20
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority:
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
qt5Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. CityrFown 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:
® 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:
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(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
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. Cityfrown 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI &MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
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
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
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
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
re Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI &MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: Vacant
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 ears usage d 283 GPD
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. Cityfrown 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: Not Provided
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI &MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
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:
Original to home
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.):
System is vented through the roof
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI &MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness 311
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
30"
How were dimensions determined? Tape Measure/Data On File
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No heavy solids at time of inspection
t5insp.doc•rev.7126I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI &MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. City/Town 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
,
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. City/Town 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 Level and at normal level
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.):
No evidence of higher than normal levels
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
U
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 6/19/20
page. Citylrown 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:
One ft of standing water in leach pit
Type:
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
�i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
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, etc.):
No sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI &MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
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
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c Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.� 16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI &MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20.
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-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Small pond in back yard is app 12ft or more below grade at front of home
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
KOLESNIKOFF, NICHOLAI & MARILYN P
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 6/19/20
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'I, 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
1 - I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information jig
on the computer,
use only the tab 1. Inspector: 6o `f
key to move your
cursor-do not Matthew Gilfoy
use the return Name of Inspector
key.
B & B Excavation,lnc.
rab Company Name
14 Teaberry Lane
Company Address
Forestdale MA 02644
Cityrrown State Zip Code
508-477-0653 SI 13640
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes �❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5/19/14
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office-of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 Ofria I fst,.n Form:Subsurface Sewage isposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
I�
` I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°,M 5 16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner' Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be consider6d a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department. .
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping inforgiation was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the r p •Ner maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
D. System Information
Description: `
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
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
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is Marstons Mills MA 02648 5/19/2014
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal Systegi Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1988
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: ` 18
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
Depth below grade: ` 12
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gal
Sludge depth:
` 3"
t5ins-11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
were H w ? scour stick
o dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
0
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
f
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
new H2O d-box installed 5-16-14
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.):
r
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching in good working condition.Water level 3'4" below invert. No sign of
hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ` ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is Marstons Mills MA 02648 5/19/2014
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
\
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 5/19/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
AI. 15
A2= 2_T6
0 M- 391
12= 23 '
0
t5ins•11/1 o
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Colonial Farm Circle
Property Address
Linda &Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: > 12'feet
Please indicate all methods used t6 determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 7-29-86
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:
plan on file @ BOH
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 16 Colonial Farm Circle
Property Address
Linda & Sanford Ader
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/19/2014
page. CityrFown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
0
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
LOCATION 1G eolpn;ml fare C,,rc)G SEWAGE# ZOIN- 131
VILLAGE ('n, M;)1 S ASSESSOR'S MAP&PARCEL 041J 19--4
INSTALLER'S NAME&PHONE NO. -2 t ,[3, EXc4%,o,,4;i7y% qJ7. 04M
SEPTIC TANK CAPACITY
LEACHING FACILITY. (type) _D QOY, (size)
NO.OF BEDROOMS
OWNER U nam Ado or
PERMIT DATE:�S j )q COMPLIANCE DATE: s-jG - j y
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
A1 - 1 C P'
F
a1 - 45-
AZ
,z' ,� r
A3.
S L4 711 q
a
0
�_ 0
No. D 7 _1 3 7 Fee Ze,al
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplitatlon for Disposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. (oUiO n t 01 '�FGt(-M Owner's Name,Address,and Tel.No.
G rc,Le.— k ncdQ-ti- 5an fa 1 (D�4da(1
Assessor's Map/Parcel a 4)L/^'q --
Installe(r'ss Name,Address,and Tel.No. IN
9� l 03 Dfe�si� is ame,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Zo
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar ealth. 5 15 C
Signed Date
Application Approved by Date +�
Application Disapproved by Date
for the following reasons
Permit No. a5:�R /14 13 Date Issued 5
i
- No.CPO/T —/3 7
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplitation for Disposal �&pStrm Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. to(D tl i G I T- P f(Y1 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Cl,z'l_y►�/,-G� - (� Vi n�Q �Gn
-. Installer's Name,Address,and Tel.No. �I L Q Design XMe,Address,and Tel.No.
", _ A
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
' Size of Septic Tank Type of S.A.S.
r
Description of Soil
P ( applicable) �� A hD)
Nature'of Repairs or Alterations Answer when a licable `
Date last inspected:
Agreement:
The The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar ealth.
-5 ( t
Signed - Date
Application Approved by Date �(
Application Disapproved by Date
t
for the following reasons
r ,-
' Permit No. 0 � A-) Date Issued S .5
- • ----------- ----------------------
THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS J - bo� U n L
Certificate of Compliance
THIS IS TO CERTIFY that N10VCL4J&0
n-site Sewage Disposal system Constructed( ) Repaired(V) Upgraded( )
Abaridoned( )by ��
at _�,b Q 1 Q I QJ(M rirGIp has been constructed in accordance c
with the proxPob:e
ions ofTitle 5 and the for Disposal System Construction Permit NoaC/I// -S7 dated
Installer FX Designer t A
#bedrooms Approved esi flow �1� I A gpdG
� 1
The issuance of p it hal n t construed as a guarantee that the system /��° d(, siggjn�d.
ns
Date ` I ector /(� r r%/ ///a) /j/,/l k
P r �_l� V
---- --------------- -- -- ----- - ----------------------------------------------------- ---------------------------------
No. y 7
�G� �✓ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Dis osal strm Construction Permit �� ~
� p
Permission is hereby granted tto"Construct( ) �Repair(V) /Upgrade(l ) Abandon
( ) `� ��
System located at l o ( .(� (�1) 1 cl
,f J
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be c'mplet I wi hin three years of the date of this pe
Date I / Approved by \ \:,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARST
required f ONS MILLS or
4 MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information When filling out I �
forms on the
computer,use 1. Inspector: i
only the tab key - ,
to move your DOUGLAS A BROWN 1'
cursor-do not
use the return Name of Inspector
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address
I CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S 14297
Telephone Number License Number
B. Certification -� --�
I certify that I have personally inspected the sewage disposal system at this address.and that the C>
information reported below is true, accurate and complete as of the time of the inspection. The-inspect n
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: :
i:z
® Passes ❑ Conditionally Passes El Fails
01
❑ Needs Further Evaluation by the Local Approving Authority
11/30/09
nspecto4Siture Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
[A
t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage
g posal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
VBY � 16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 11/30/09
every page. Cftyrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 MEETS MINIMUM PASSING REQUIREMENTS AT THIS TIME. PIT IS DRY WITH STAIN
LINE AT 10 INCHES FROM BOTTOM OF INLET PIPE
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
` Commonwealth of Massachusetts
Title 5 Official Inspection
p coon Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
tSms-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS
required for MA 02648 11/30/09
every page. Clty/Town State Zip Code Date of Inspection
B. Certification (Cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
` Commonwealth of Massachusetts
Title 5 Official Inspection Form o rm
Subsurface Sewage p
Disposal g p al System Form -Not for VoluntaryAssessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is
required for MARSTONS MILLS MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 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 D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS
required for MA 02648
11/30/
09eve every page. Cltyrrown State Zp Code Daeins
pection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Fo
rm
rm
Subsurface
Sewage Disposal System Form- Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is
required for MARSTONS MILLS MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND A 1000 GALLON LEACH PIT WITH
A STAIN LINE @ 10 INCHES FROM THE BOTTOM OF THE INVERT PIPE
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): 08-290/07-241
Detail
THIS PROPERTY HAS A IRRIGATION SYSTEM
Sump pump?
❑ Yes ❑ No
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes
❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS
required for MA 02648 11/30/09
every page. Ci mown State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
0 Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS
required for MA 02648 11/30/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
SYSTEM APPEARS TO BE ORIGINAL FROM 1989
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 GALLON
Sludge depth: TRACE- HOUSE VACANT
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 9 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 11/30/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness TRACE HOUSE VACANT
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
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 LOOKS FAIRLY CLEAN AT THIS TIME PROBABLY BECAUSE THE HOUSE IS VACANT
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
AM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
'( 16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 11/30/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ms-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM 16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS
required for MA 02648 11/30/09
every page. City/Town State.) Zip Code DateofInspectionD. Sy emIfnormation (cont I
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX IS LEVEL WITH NO SIGNS OF LEAKAGE BUT DOES LOOK TYPICAL OF ITS AGE WITH
SOME CORROSION
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 16 COLONIAL FARM CIRCLE
Properly Address
CATALANO
Owner Owner's Name
information is
required for MARSTONS MILLS MA 02648
every page. City/Town 11/30/09
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions-
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology.-
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
PIT WAS DRY AT TIME OF INSPECTION WITH STAIN LINE @ 10 INCHES FROM THE BOTTOM
OF THE INLET PIPE
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 113 of 17
Commonwealth of Massachusetts
Title 5 Offici
al Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is Owners
MILLS
required for MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information cont.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site
plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5ins•Og/os
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is
required for MARSTONS MILLS MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsur
face Sewage Disposal System Form Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Properly Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS
required for MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12 FT+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
OFF PREVIOUS INSPECTION DATED 3/15/96 BY J.P. MACOMBER
Before filingthis
his Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09=
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 COLONIAL FARM CIRCLE
Property Address
CATALANO
Owner Owner's Name
information is MARSTONS MILLS
required for MA 02648 11/30/09
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth.to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
2; c,+C,-l"C)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
- - _ SYSTEM INFORMATION(continued)
PropertyAddiresa;16 Colonial-Farm__Circ -& Marsts Mills Mas 02648
Owner. —,- ._ -. - - - ---
Unique Real Estate
Date of Inapeotion:3/1 5/9 6 -
810"CH OF SEWAGE DISPOSAL SYSTEM: •
include.tier to at least two Permanent references landmarks or benchmarks
locate all wren&wkhin 100'
Centerville,Osterville.,Marstons Mills Water Company
428-6691
1
DEPTH TO GROUNDWATER
Depth to twundwater.l�feet S t N i VP /i ock ti/ ny( GI
method of
determination or approximation See a A N o e W 1
9 water encounte ed at 12 +
(revised 11/03/95)
9
•,U Commonweal
th of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Ulla:n F.Weld Trudy Coxe
Wullar .6—suq
comr '
Argeo Paul Celluccl David Boom e
t1 Gowmor
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION y
f Owner.
Add l Ci
16 Colonial Farm Circle Address or. ;3
Property Address:
Date of Inapeo46n:3/15 9 6 (It different)
Name of lnspector-Joseph P. Macomber Jr.
Company Name,Address and Telephone Number. s A
y ? a ,�
Son Inc. Box 66 tenterville,Mass. 2632 e 9
J.P.Macomber & S 4�4 , 6
CERTIFICATION STATEMENT 508-775-333$ ° °
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below 34 true,accurst!
unction
n.�
and complete as of the time of inspection. The inspection was performed based on nay training and experience in theproper
stem .Yr '
maintenance of on-site sewage disposal systems. The sy
,Passes ,
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Falls li4
Iaspector'a Signet Date: h
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system Is a shared system or has a design flow of 10,000 SO or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A.B.C,or D:
AI SY9_ 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.
BJ SYSTEM CONDITIONALLY PASSES:
' One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
Inspection.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial ioMtration or ex.Mtration,.or tank failure is
immin nt. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
J by the Board of Health.
(revised 11/03195) I
One Winter Street a Boston,Massachusetts 02108 1 FAX(611)556-1049 a Telephone(617)292.5500
�► !Printed aj Recycled PIPn ,
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontlnued)
PropertyAddressr 16 Colonial Farm Circle Marstons Mills,Mass. 02648
Owner: Unique Real estate
Date of LuP"tion:3/15/9 6
Bl SYSTEM CONDITIONALLY PASSES(coutin0ed)
Sewage backup or breakout or hA static water level observed in the distribution box is due to broken or obstructed pipes)
or due to a broken,settlad or uneven distribution bon. The system will pass inspection if(with approval of the Board of
Health):
broken pipes)are replaced
obstruction is removed
distribution boa is levelled or replaced
The system required pumping more than four time a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipes)are replaced
obstruction Is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
AAD_ 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 ENVIRONMENT1
AI/¢ Cesspool or privy is within 60 feet of a surface water
Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh.
_ Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM 1S FUNCTIONING 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 within a Zone I of a public water supply well.
�Q The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private water
supply well,unless a well water analysis for aoliform 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.
S) OTHER .
AX
(revised 11/03/95) 3
f
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Pro pertyAddress: 16 Colonial Farm Circle Marstons Mills,Mass , .02648
Owner. Unique Real estate
Date of Inspection:3/15/9 6 e
DI SYSTEM FAU-M •
•
I have determined that the system violates ens or more of the following failure criteria as defined in 310 CMR 15=& The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be nscwssary to correct the
!aide. .
d& M1 Bacl-up of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or poading of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
dj Static liquid level in the distribution box above outlet invert due to an Overloaded or clogged SAS or cesspool. .
lg'vX Ptr
depth in is less than•6"below invert or available volume is less than 112 day flow.
A�! Liquid 1sr sesspeel
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped--.
A 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.
dM 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 fmm a private water supply well with no
acceptable water quality analysis. If the well has,been analyzed to be acceptable,attach copy of wall water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the systemic a signiScaat 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
A0 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!!other information..
(revised 11/93/95) 3
- • Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
propertyAddresa: 16 Colonial Farm Circle Marstons Mills ,Mass. 02648
Owner. Unique Real Estate
Date of Inspection:3/15/96 •
Checklif the following have been done:
2p=ping information was requested of the owner,occupant,and Board of Health. ,ew�'j'e 1�' r .+l�' 1�fy"
None of the system components have been pumped for at least two weeks and the system has been'receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
,LlAs built plans have been obtained and examined. Note if they are not available with N/A.
, The facility or dwelling was inspected for signs of sewage back-up.
- The system does not receive non-sanitary or industrial waste flow
,/The site was inspected for signs of breakout.
2AU system components,4tcluding the Soil Absorption System,have been located on the site.
ZThe septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of banes or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
, The six and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
, The facility owner(and occupants,if different from owner)were provided with information on the proper maintenaace of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL: •
Design•flow: ns •
Number of bedrooms:
Number of ausent residents:jL
Garbage grinder(yes or no):_VQ S
Laundry connected to syste (yes or no):,,
Seasonal use(yes or no):
Water meter readings,if available:
,l� D
rt el�,IIWAI gtuX,Z,�
f_
Last date of occupancy:
COMMERCIAL NDUSTRIAI.
Type of establishment.
Design flow: V4 ns/day
Grease trap present:(yes or no)&l
Industrial Waste Holding Tank present:(yes or no)JL
Non-sanitary waste discharged to the Title 6 tam: (yea or no)AD-
Water meter readings,if available: �(1
Last date of occupancy: Al
OTHER(Describe)
Last date of occupancy:_
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection:(yea or no) S
If yes,volume pumped: ns
Reason for pumping 0 L J"4
TYPE Oy B tic EIM
to
kol Septic taalddiatrlbution bax/aoil absorption system
Singis cesspool I Overflow cesspool
0 Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
JX Other(explain)
APPR03RMATE AGE of all components,date installed(if known)and source of information �v214f/`S d!✓� ��� �D/ Pi
Sewage odors detected when arriving at the site:(yes or no)
(revised 11/03/95) 6
�W TOWN OF BARNSTABLE
LOCATION '-o-�. �l Cd�oti.�al '�•c C; +AG13 #
ASSESSOR'S MAP Q LOT
�IN$TALLER'S NAME & PHONE NO.. �'��` . Pei It I = S4n-
S.SPTI TANK CAPACITY_
THING FACILITYAtype) 417 (size)
NO .'OF BEDROOMS �PRIYATE LL OR LIC
$UNDER OR OWNER S
P-4-TA::PERMIT ISSUED:
DATE' COLIPLIANCE ISSUED•
VA ti:ANCE GRANTED: Yes No
i
-
• �,
r 1 a.1
i ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 Colonial Farm Circle Marstons Mills,Mass . 02648
Owner. Unique Real Estate
Date of Inspection:3/1 5/9 6
SEPTIC TANKL—AW 9,f Z&V ZPAb e
(locate on site plan)
Depth below grade: oil -
Material of:constructiou:Zncrets metal_FRP other(explain)
Dimensions: < t =
Sludge depth:`"
Distance from top of sludge to bottom of outlet tee or baffler
Scum thiclmeos:_Lo _
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:__
Comments:
(recommendation for pumping,condition of islet and outlet tees or baffles,depth of liquid level in relation to cutlet invert,structural integrity,
evidence of leakage,etc.)' Pumps e t i c tan --
are' re ent n e is tank i
Pumped septic tank at time of ins ect'
382. o evidence of at
GREASETRAP:Ayt/,L,-�- this time.
(locate on site plan)
Depth below grads:-4(-&
Material of construction:4(Aconcrsts_metal_FRP other(explain)
)P)J
Dimensions: At )l
Scum thickness: Jl A
Distance from top of scum to top of outlet too or bafIIe: A),9,
Distance from bottom of scum to bottom of outlet tee or baffler
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.) 21d (Js.yl er1G.d7 ei
(revised 11/03/95) e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued) .
PropertyAddrw 16 Colonial Farm Circle Marstons Mills,Mass . 02648
Owners Unique Read. estate ,
Data of Inspections 3/1 5/9 6
k
TIGHT,OR HOLDING TAM_4iW, .`
pocnte.on site plan) • ,
Depth below grade.,
Material of oonstr<utionv ooncrvte _YRP cther(ezplain)
Dimensions: OOA
Capacity: s9A gallons.
Desiga flow: ns/day
Alarm level:
• Comments:. '''::
(ooudifion of inlet tee;condition of alarm and float switches,etc.) f
A, GA cH yl9�.ri l
DISTRIBUT;ON BO&�" ~� ; '� 1•
(locate on sits plan).
Depth of liquid level above outlet invert: Alo
Comments: s:
(note it level and distrsbution Is aqua),evidence of solids carryover,evidence of leakage into or out of bauc,'etc.)
'Box level "and distribution is a ual+
_o evi ence ' o leakage in or out of thA cj; Qtr;1,,,+.3 , ,x„ No reBair,_s
re e _e At th, rAAA +. +.ima
PUMP CM MBEIt 'i,,
(locate on site plaW
Pumpe in working order:(yes or no) - .
Comments: , ...
(cote condition of pum condition of pumps and appurtenances,etc.)
,• Per. .
i
�.(revised.tvo3�95) • � s .. �'(w��airr ��y��) 1' ; ,
SUBSURFACE SEWAOE DISPOSAL SYSTEM INSPECTION FORM
SYST^1.: I" :J?d (oontinued)
Property Address: 16 Colonial Farm Circle Marstons -Mills,Mass. 02648
Owners Unique Real' Estate
Date of Impeotions .3/1 5/9 6
SOIL ABSORPTION SYSTEM(SAS)1Z '
(locate on sits plan,itpossible;excavation VA requirV but maybe approximated by non-intruaiw msthoda)' . . . ;;
If not diterminod to be present,explain: •
laachin pits,number.,1,
lbaching galleries,nnumber._.O_
leaching tronches,number length r
leaching Aside,number, na•,
overflow cesspool,number.
Comments:(note condition orsoil,signs of hydraulic failure, lrvr! cond:tion of vegetation,etc.)
Soils . see uaae".9A.No signs of hydraulic failure or � on in
y*U at; on is norm 1,;�i���;r3 level ; �12�� below invert Sipe to the sac iris
mr•+ 1�,F, 5A anilnn nn n? rit.or AVA; IAhIP ;n the IPAr+h;ng• pit.
CESSPOOLS: m •.. �...
(locate on site plan)
Number and configuration:_ AM
Depth-top of liquid to inlat invert: Wo
Depth of solids layer: al
Depth of scum 3gyer:_ �)
Di-eadoas of cesspools•
Materials of construction:
Indication of groundwater:
• inflow(oesspool must be pumped as part of inspect:;,:?_
Comments:(note condition of soil,signs of hydraulic failvro, !-•vd sf condition of vegetation,etc.)
PRIVY;41
(locate on site plan) .
Materials of construction. �/9 Dimensions:
Depth of solids:, t1W,
Comments}(note condition of soil,signs of hydraulic fallur., .:on of vegetation.etc.)
D ��z4•tl�Y S
(revised 11/03/,.95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddre.e: 16 Colonial Farm Circe Marstons Mills ,Mass . 02648
Owner. Unique Real Estate
Date"InsPeotion:3/15/96
SKETCH OF SEWAGE DISPOSAL SYSTEM: e
inChIde ties to at least two permanent references landmark or benchmarks
locate all Maus within 100,
Centerville,Osterville,,Marstons Mills Water Company
428-6691
%, ,f
DEPTH TO GROUNDWATER
Depth to vmndwater.A�L—feet
method of determination or appsozimatio= See page 9A No water encountered at 1 2!
rn�al l cry in 1 URR 382
(revised 11/03/95) 9
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TOWN OF Barnstable BOARU OF HEALTH
I SUBSURFACE SEWACF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
h...�r. ��...-..a-r. �-.rrnmrm•rt:.:n rzre:rnr.rr-nt'r-•.•:rz.rs+:z assr*.++"•a-+-n++c+.a*r rarre+e**ac�'r+ss'o rsmnr*m•rrnaa•+srrr►m:v++re-r•r+•-•••••.�
-TYPE OR PRINT CI.EARLY-
P1t0PERTY INSPECTED
STREET ADDRESS 1A rnlnnial Farm. Circle Ma_rstnns Mi118,Mass. 02648
ASSESSORS MAP, BLOCK ANLf PARCEL
OWNER' s NAME nniqiie Rawl Estate
>� Pn117' ll - CERTIFICATION I
NAME OF "INSPECTOR Joseph P.Macomber. Jr.
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66, 0enterville,Mass . 02632
Street Tovn or City State LIP
COMPANY TELEPHONE ( 508 775 3338 FAX ( 508 790 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance, :and repair are consistent
with Iny training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
Systeui PASSED
The inspection I4hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
A
Inspector Signatur ` Date � �� '
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the I3OAnD OF }ILrAL1'I1.
* If the inspection FAILED., the owner �or operator shall upgrade ' the eyutem
within one year of the date or the ins`:pection ,_ unless allowed or required
otherwise as provided ;in_3,1_0_CMR 1.6 . 305 .
• F
Price
Address 16 Colonial Farm Circle �T
Town' Marstons Mills
1.i..1 QUE
U ,
Acreage 0.35 REAL ESTATE
Age 6
Dist.'to Salt Water is 2-3 miles '
Waterview Yes
Waterfront No
Square Footage 2,200
Assessment 219,900
t -
Land 40,900 I-
Building 179,000 == �•
Total.Taxes $2,863 �►0-, _ �
Deed'Ref. 7007/105
Map/Parcel 44/9.6 IN
Sti l Water
, pp Y �. Town -
Sewerage Sys.t Private
Deed Restrictions Yes
Rental Income None
In-Law Apt. No
Condo Fees No
Assoc. Fees Yes
No. of Rms 7 Bedrooms 3 Baths 3
EXTERIOR INTERIOR ROOMS- 1ST FLR 2ND FLR
Style Contemporary Floors Wall-to-Wall Living Room 26x14
Roof Architectual Fireplace Yes Dining Room 13x11 -
Siding Clapboard Stove No Eat-in kitchen (16x13x9x11)
Color Pastel Green" Refrigerator No Bath" 2 Full 1 Full
Foundation Irreg. Stove Yes Master BR 1707
Storms Yes Microwave Yes BR 2 14x12
Screens Yes Dishwasher Yes BR 3 20x17 ,
Heat ; Gas/HA Disposal No BR 4
Hot Water Gas Compactor Yes BR 5
Amps 200 Washer Hooky Yes BR 6
Insulation Yes Dryer Hookup Yes Family Room 14x13
Underground sprinkler Yes Dehumidifier Yes Den
Garage 2 Car AC Yes Deck Cedar deck
Central vacuum Yes Smoke Det. Yes Porch No
Driveway Paved Basgment Wlk-out Laundry L1 7.5x5
Listing Agent Colleen Ryan Comments: PRESTIGE HOME IN PREMIER LOCATION!!
Owner EXCITING CONTEMPORARY W/ SPECTACULAR PONDVIEWS .Y a
Phone# IN THE HOMESTEAD. FEATURES INCLUDE OPEN & SPACIOUS
Key# ROOMS, CENTER ISLAND IN KITCHEN, LARGE MASTER
Listing Type: SUITE W/ JACUZZI, COZY FAMILY ROOM, & MUCH MORE.
Showing Instr. Call listing office Directions: RIVER RD TO OLDE HOMSTEAD TO COLONIAL
FARM CIRCLE.
All Brokers/Salesperson represent the seller,not the buyer,in the marketing,negotiation and sale of property,unless otherwise disclosed.
However,the Broker/Salesperson has an ethical and legal obligation to show honesty and fairness to the buyer in all transactions. Offering is
subject to errors,omissions,change or withdrawal without notice.
404 Main Street, Centcnille,.Kk102632 , Pli one (508) 778.4036 Facsimile (508) 775.0885
146 Main Street, Osten,Wc, MA, 02655 Plione (508) 428:7732 Facsimile (50%428.8012 .t
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LOCATION=G� �' CC)'c3V.\,c" t�,l �F�GE�VAGE #
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,INSTALLER'S NAME & PHONE NO.��'�j���
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'4 SEPTIC TANK CAPACITY_1 0�
hEACHING FAC.ILITY:(type)r (size) Q /
4NO. OF BEDROOMSry.� `
.� PRIVATE 'MFCLL OR U LIC
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCh ISSUED:
VARIANCE GRANTED: Yes No
c
A
V
6� T WN OF BARNSTABLE
LOC TION ` r'�v C+�AAGE # Z
VILLAGE Mg(i r S S ASSESSOR'S MAP & LOTO -004
INSTALLERS NAME & PHONE NO.�� i�(�j(_� S�
ASEPTIC TANK CAPACITY_�
hEACHING FACILITY:(type)_ I (size) /'7—
E .
NO. OF BEDROOMS ,� PRIVATEZL OR LIC
BUILDER OR OWNER (
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
1�� � 'j�
e�
� !�
ASSESSORS MAP NO:
PARCEL NO.: �7�- f
C?0, THE COMMONWEALTH OF MASSACHUSETTS
57L—
BOAR® OF HEALTH - U
------.... izc ............0F......i& n,Q. LL�_ _....................
Appliration for Diapnsal Works Tonstrurtion rantit
Application is hereby made for a Permit to Construct (.,p) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Addre t No.
.... Q ,,�...... ...._.. - >
W Ow Address
a A - ...... LJ /ti'�.Q Q�/C ...........................................
Installer Address
UType of Building Size Lot...i5,1_44p......Sq. feet
a Dwelling—No. of Bedrooms..... ........�s_IR,____._.___..__._Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q, Other fixtures .---....._--••- ••---•----•-......--•--------••--
W Design Flow...........55.........................gallons per person per day. Total daily flow-----s ..30............_...............gallons.
Septic Tank—Liquid'capacity"I).gallons Length___....$:..... Width......&._...... Diameter________________ Depth................
W
x Disposal Trench—No_ ____________________ Width_____AV........ Total Length.................... Total leaching area_...................sq. ft.
Seepage Pit No-----------l......... Diameter.......$./....... Depth below inlet.......42......... Total leaching area..o?Ve).....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.1Jffl-__ (J�1iL c11C ............................ Date....' PL �$ ._._._...____..
Test Pit No. 1-----;&_------minutes per inch Depth of Test Pit.................... Depth to ground water.........................
f�. Test Pit No. 2................minutes per inch Depth of Test Pit-_______---.___----. Depth to ground water______-____-_-_-__--__-_
Description of Soil Qi�. o ¢ ........---- ------------• •-----•--•---•----------------
----------------------- v�.. �1
wIEW..-•--••--------•-•-
UN ture of Repairs or Alterations Answer when a p ' ble.... ......................................................................................
�Agreement: C-I-)
The undersigned agree st 11 the afore d d n v' ual e , ge Disposal System in accordance with
the provisions of TTT s.t
p 5 of the S to Sanitary o —Th nd d further agrees not to place the stem
operation until a Certificate of Compliance has b issued b r of health.
Sine --------------------........................... -----� - -----•-
11 ate j
Application Approved BY {:. _. ..... — ,.......... ` 1 ---
Date
Application Disapproved for the following reasons________________________________________________________________________________________________________________
.....................................................------------------....-----........----------....--•-------...........---•----••-•-------•--•-•--•-•--•-•--------•-------•-------•-••••-----------
Date
Permit No....... Issued.......................................................
Fxs.7.51.Cz 4e.._....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r.rix _......O F....f��It r t.t'l . ll -------------------------------------------------
Appliration for Db6p i al Works Tomitrnr#inn ramit
Application is hereby made for a Permit to Construct (p ) or Repair ( ) an Individual Sewage Disposal
System at:
...... .P_------L',(21�-4�..Le----------- -- . try --------
Location-Address Jf of No.
t 11'VU'a ---------------------------------------------- l � a .__..1'' .------.....---------------------------.._.----
,_..
Owner 13& Address
Installer Address
Type of Building Size Lot..l.Cj,_A_-•1. --------- feet
Dwelling—No. of Bedrooms___3........�..1....................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Other fixtures .......................................................................................................................................................
No.•-of persons............................-Showers (---•)•— Cafeteria (---)• �
W Design Flow.........5 5..........................gallons per person per day. Total daily flow---. 34''.._......._._................_.gallons.
W Tank—Li c Se ti Tank—Liquid caacit C` _ 1
P q P Yf -LO.._gallons Length -�---•--- Width----�--------. Diameter---------------- Depth................
x Disposal Trench—No. .................... Width... .......... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------I----------- Diameter.....$._'......._. Depth below inlet................. Total leaching areadOjC).......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.CsItT!...... 11XC_ .r............................. Date...'!1'22 5js.lp................
Test Pit No. 1---d-_........minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 -•----------------------------•-•-------•--•---•----••--....---••------•..........--•--...---................................................................
0 Description of Soil :: 1 r p._. . /1.! ...n0c :' --------------------- --------
x
UW �f CO1.1r1.�&—d--------------------------------------- -------------------------------------------------------------------------------------------------------------- -----� -
iture of Repairs or Alterations Answer when a p" ble... .. ...........................
<-•� --- -- .....•--•--•-----..----- ------- ---------------------------` --- . ------------------------------------....--•---
Agreement: \� J �.
The undersigned agrees tom st 11 the afore s ed n vi ua/ age Disposal System in accordance with
the provisions of TITLE '5 of th S ute Sanitary e—Th un i ed further agrees not to place the ystem
operation until a Certificate of Compliance has b issued t d of health.
7
Sign •........•... ..... ........................... ............••------•------ .
_ ...........
Date
Cr i r
d---------------
Application Approved BY Da
te
Application Disapproved for the following reasons:...............................................................................................................
--••--••-------------------------------------------------------------------------------------------------•---------•-----------•--•-•-•--•-----••--•--•---• -•-•-----•----•---•------•-•-----•-•......--
Date
Permit No.... Issued................••••----•--•-----•----
..
---- ---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t!c z-^✓...................OF.... C .Yt ) Gl.(9't ...........................................
Tntifiratpof f�nut liu�tr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed gip ) or Repaired ( )
bY...Ica_i'4-XA ......................------------------------------------------------------------------------------------------------------
IInstaller
atl of----I f r�_1, 1.i.ej:...JQA.M----- ............ ...... -------------------------------------
has been installed in accordance with the provisions of T i.LIE j of The St to Sanitary Cod as dgscribed in the
application for Disposal Works Construction Permit No..... .... �d_ated_...����'11-_�'(a_________________
TIME ISSUANCE OF THIS CERTIFICATE SHALT. NO B CO ROE® AS A GUARANTEE THAT 7HE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................................................................••......-_..... Inspector...:................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��..
F ........................
�i��n��tl nrk� �nu��rinn rruti�
Permission is hereby granted...KP fit-Y-l....... 1. . :...................._..
to Construct ( 6) or Repair an Individual Sewage/�isposal System
2t i�'o. t'E.._.A1C_tLY L L!�._.... ....--• .............
Street 3
as shown on the application for Disposal Works Construction Permit N ................. at .._....... �t�.___...__'_.........._.
� T ,
................... t- -
r 1 �`-��.lti- `J l ) Board of Health
.�AT1 C-" -•-----•--•......---••-.------•••....-•---------�......
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS `
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PETER 4_ SULLIYAN
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