HomeMy WebLinkAbout0043 COLUMBIA AVENUE - Health 43 Columbia Avenue
Marstons M F/p
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Commonwealth of Massachusetts 103 olay
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Columbia Ave
Property Address +"
Tivey
fin
Owner Owner's Name
information is ✓ -r-
required for Marstons Mills MA 02648 2-1-18
every page. City/rown State Zip Code Date.of Inspection
I-1.
U l
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 54 /60/ a
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2-1-18
:�Ins or's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
M AWTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
—90o 43 Columbia Ave
Property.Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
At time of inspection this system met all passing requirements. This report is not to be used for
bedroom count. This report can not predict the future performance under the same or increased
useage. Septic tank appears to be-original and leaching is from 3-24-04 per as-built:
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Columbia Ave
Property.Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5ey`9v 43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown 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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 43 Columbia Ave
Property Address
Tivey
Owner Owners Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Columbia Ave
Property.Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
El ® 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
r
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
A 1000 gallon septic tank, d-box, and a 10'x37'xl 1" s.a.s of infiltrators with stone according to plan
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
2016----96 gpd 2017----33gpd system is not designed for use with garbage disposal.
Sump pump? ❑ Yes ❑_ No
Last date of occupancy: summer of 2017
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: summer of 2017
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ . Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property.Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
tank original s.a.s 2004 per as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below crade: feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from 1private water supply well or suction line: feet
Comments(or condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 8 inches
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth: varying but light to moderate
t5ins•3113 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
43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness trace
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? scour pole
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
If tank has not been pumped in the last 3 yrs I recommend pumping at time of transfer and at least
every 2-3 yrs there after for maintenance. Tank showed some light corrosion typical for its age. there
was also some light root intrusion.Tank was functioning properly.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM
43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes' ❑ No
t5ins•3113 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
43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid,level above.outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
box was level with no signs of solid carry over. I recommend installing a riser at some point to bring
cover closer to grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
There were no observation ports on s.a.s. I was able to go down the vent pipe with a snake and it
came back clean and dry.
t5ins-3113 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
43 Columbia Ave
Property.Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5 infiltrators with
stone 10 x37 x11
❑ 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.):
There were no observation ports on s.a.s. but I was able to run a snake down vent pipe and it came
out clean and dry. Exact leve of ponding and-or staining could not be determined.
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
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: greater than 5
feet
I
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: 2-1-18
Date
Observed site(abutting hole within 150 feet of SAS
❑ ( 9 )
❑ 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:
design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Assessing As-Built Cards Page 2 of 2
http://www.townofbamstable.us/Assessing/flMdisplay.asp?mappar--103024&seq=2 2/2/2018
r
Commonwealth of Massachusetts
Title 5 official- Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,. 43 Columbia Ave
Property Address
Tivey
Owner Owner's Name
information is required for Marstons Mills MA 02648 2-1-18
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15-or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f
Assessing As-Built Cards Page 2 of 2
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=103024&seq=2 2/2/2018
Assessing As-Built Cards Page 1 of 2
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ERWrDATE: COMPLIANCE DATE:
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daximum Adjusted Groundwater Table to the Soctom of I caching Facility F�
4lvate-Water Supply Well and Leaching Facility.(If any wells exist
on site or widda 200 feet of leaching facility) Peet
,'Age of Wedand and Leaclting Facility(If any wetlands exist
within 300 feet of l ping Imility) Feet
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http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=103024&seq=2 2/2/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
* - Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name w ,,
information ie Marstons Mills 'MA 02648 9-4-1.2
required for every
City/Town,.,/Town," ,
a e. s" State- Zip Code Y , Date of Inspection
P9 P P
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.
A. General Information
1. Inspector. .. 1'Ic
Vb
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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. 1 am a DEP approved system inspector pursuant to Section 16.340 of
-Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation'by the Local Approving Authority
-
9-4-12
Inspector's Signature F 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.
LUCqllrol�cv
t5ins•11/10 Title 5 Offic In coon Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 43 Columbia Ave
Property Address
t
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-4-12
'
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
Inspection Summary:,Check A,B,C,D or.E/always complete all of Section D
A) System Passes:
®�I have not found any information,which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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):
t5ins•11110^ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name s
' >' every
required for every_
information i Marstons Mills MA 02648 9-4-12 `
. ,
page. ,City/Town rs.'.•, State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed' ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced - ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11l10 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
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Marstons Mills
required for every MA 02648 9-4-12
page. City/Town State Zip Code Date of Inspection
e
B. Certification (coat.)
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 forma
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
F due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
"or clogged SAS or cesspool
El
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than YZ day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
t c
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is' Marstons Mills MA 02648 9-4-12
required for 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.
r .
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is`a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
❑ ®'' criteria exist as described in.310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve.a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ . the system is within 200 feet of a tributary to a surface drinking water supply
❑ El Area
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.
[Sins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
- t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�qM 43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-4-12
page. City/Town State Zip Code Date of Inspection
C. Checklist.
Check if the following have been done. You must indicate"yes" or"no" as to each of the following.
Yes No.
❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® . Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
` ❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
t, available note as N/A)
" ® ❑u I ,Was the facility or dwelling inspected for signs of sewage back up?
® ❑ -Was the site'inspected for signs of-break out?
i.
® ❑ ` Were all system components, excluding the SAS, located on site?
El ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
i 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?
P P• g P Y
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 w Number of bedrooms (actual): 3
' DESIGN'flow based on-310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
'*
t5ins-11110 n" Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned,(Contact,David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name F
information is .
required for every • MarStonS Mills MA 02648 9-4-12
_ ,�,;-
page. Cityrrown• - State Zip Code Date of Inspection
D. System Information
Description:
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
v
Seasonal use? . ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
6-2012
Last date of occupancy: Date
Date
Commercial/Industrial Flow Conditions:
Type of Establishment
Design flow (based on 310.CMR 15.203): Gallons per day(gpd)
i 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
J
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-4-12
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: N/A
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
y_ r ,
❑ 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•11110 F Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
f Owner Owner's Name
information is required for,every Marstons Mills MA 02648 9-4-12
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:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 3"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:
12"
t5ins-11/1 o Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
0 Title 5 official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-4-12
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
20"
{Scum thickness lit
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined?
Tape
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 is in good condition with baffles installed and no sign of leakage.
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 um in :
p P g. Date
t5ins-11110 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
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Marstons Mills MA 02648 9-4-12
required for every -
page. City/Town ', State Zip Code Date of Inspection
D. System Information cont.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: ,
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Marstons Mills MA 02648 9-4-12
required for every
page. City/Town State Zip Code Date of Inspection
D..System Information (cont.)
a
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.):
Good condition with water at working level and no sign of back-up from field.
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):
h 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
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
• 43 Columbia Ave
Property Address
Bank Owned (Contact David Holt c@D.Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is every Marstons Mills A '�� -
re equ wired for eve _ MA 02648 9-4-12 '
page. CityTrown State Zip Code Date of Inspection
D. System Information`(cont.) r
Type '
❑ leaching pits number:
® leaching chambers number:
5-Infiltrators
❑ 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.):
Infiltrator leach filed in good condition with no sign of back-up into d-box or surrounding stone.
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
I
r,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is tons Mars Mills r
required for every MA 02648 9-4-12
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.):
4
t5ins•11/10 +, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
g Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
$' Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
'Owner Owner's Name
information is required'for every Marstons.Mills MA 02648 9-4-12
page. City/Town, j 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
t
t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today'Real Estate 1-800-966-2448)
Owner Owner's Name
information is Marstons Mills MA 02648 9-4-12
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
i
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtain'ed from system design plans on record
rlf'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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins 11/10 f 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Columbia Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Marstons Mills MA , 02648 9-4-12
required for every
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information-Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
f
I i
f _
p '
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
7� C/�•� �
.00A��zoN � a 406 sEwACE #
,11LLAGE ya154%s 11k1115 ASSESSOR'S lM &LOT._�.�.
NSTALI-ER'S NAARE&PHONE NO.
iEPTIC TANK-CAPACITY I
t
,EACMNG PAC:ILrff: (ty ) ? /u rS (size) /0 L7'Xll'r
MILDER OR OWNED...,.
'E ITDATE: COMPLIAAICE DATE:
leparation Distance Between the:
Aaximutn Adjusted.Groundwater'I`able to the Bottom of Leaching Facility
'wale dater Supply Well and Leaching Facility (If iuiy wolls exist
on site or within 200 feet of leaching facility)
idge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of/caching facility) + I ect
Burnished by �wH
cK
1
A-D-l9L
LCICA.TION r J COI U"I A AA, SEWAGE #
. i
VILLAGE. ✓✓!. ✓Vh AS ASSESSOR'S MAP& LOT O
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /on FA LED INSPECTION.
LEACHING FACILITY: (type) �X�. P7" (size) 66T
NO.OF BEDROOMS 3
BUILDER OR OWNER (I S� �OU!/1•G/
PERMTTDATE: COMPLIANCE DATE:
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 Til SDc.06 , rDlle—i
A
n U�
0 o
a� 1-7 a�
0
3
3 � �8
#L13
L'OC. ATI SEWAGE PERMIT NO.
VILLAGE
0
INSTALLER'S NAM i ADDRUSS
B U I L D E R OR OWNER
a.
DATE PERMIT ISSUED g
DATE COMPLIANCE ISSUED � _� � _
< . ,�
'�
�I
��
/ �
( �
l�
TOWN OF BARNSTABLE
A I SON C_ Est t7�4- �Q SEWAGE
VILLAGE ASSES 'S MAP & LOT /0.3-421/
1
INSTALLER'S NAME&PHONE N0. a
Z
C TANK CAPACITYi ✓'
ACHING FACILITY: (size) /Df)C37C wt"
NO.OF BEDROOMS_
BUILDER OR OWNED
PERMITDATE: 7 b y COMPLIANCE DATE:
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
bi '
Noc�y04-/ —10U� FEE 50 '-
COMMONWEALTH Of MASSACHUSETTS
Board of Health,
APPLICATION FOP, ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair>41 Upgrade( ) Abandon( ) - ❑Complete System�Individual Components
Location niaOwner's Name Ll �, IFOMVe
Map/Parcel# 1O Address .
Lot# 4r S Telephone#
Installer's Name `C Designer's Name A 1
Address Address M�
Telephone# (aL Telephone#
Type of Building �� tt�' Q� Lot Size cQO BWO sq.ft.
Dwelling-No.of Bedrooms ���� 3 Garbage grinder (*Y/A,
Other-Type of Building No.of persons CQ- Showers V,Cafeteria
Other Fixtures LC3'k-, C A { -�-[o Slm`C . L[lilt>�cta
Design Flow (min.required) 33fl gpd Calculated design flow 990 Design flow provided $gpd
Plan: Date 3 1LAI O 4- Number of sheets Revision Date �-
Title D� ^� �1C Su S _� P _ tt
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 3 OZ 04
DESCRIPTION OF REPAIRS OR ALTERATIONS ~'To Q r-V&& ;P`Qt-,, -
The and igned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to t to lac tem' operation until a Certificate of-Com lianc has been issued by the Board of Health.
Sign d Dat
Inspections
/v.'..`.l't�`"'".a7.'"�-•.••ti,"�'"f`3""+.'."a'�-`�+'1.s�•wJ�'x�.,•.-.y.or-•+.f�^.�-',�»+,,f�,r.4+:.sk^+re-.`n..w+�,..r�'�'?+"1�''."'.,,;�,Y�v+•'"�"'�'K'''.ya„i.•,rs`'"�,+_..:.��,.�r+,,•----•...
—�
' No. FEE
COMMONWLALT14 ®F MASSAC14USETIS
Board of Health, \6e MA.
APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair Upgrade( )` Abandon( - ❑Complete SystemXIndividual Components
Location Owner's Namer 0 � A �70W.)M e r
Map/Parcel# ,Q 1AS (7)rQ 4 J Address �M
Lot# a, Telephone# �-+
Installer's Name r ,� �v�C Designer's Name !-\A\� Z(l�1COi�i`t12f1'tC` US•
Add Address " Address
'Z"c�p c� ox (oa . Fa . MA-
Telephone# (ply _� \�� Telephone#
Type of Building , Lot Size 620, AM sq.ft.
Dwelling-No.of Bedrooms I'��P� 3 T Garbage grinder (t)lp,
• Other-Type of Building � Q No.of persons r2 Showers (�Cafeteria V
1
Other Fixtures Ln 'n {CA 60 r\ Sink Ln oric tru
Design Flow(min.required) D --)gpd Calculated design flow. Design flow provided gpd
Elan: Date 12�, ` I y Q 4 Number of sheets Revision Date
Title
Description of Soil(s)Soil Evaluator Form No. Name of Soil Evaluator( ��iY1R r1 S Ay Date of Evaluation 10
DESCRIPTION OF REPAIRS OR ALTERATIONS "m ai k r,.r V-,e
t
t
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
y further agr\es to ^ot to place the-system in.operation until a Certificate o/�•Com fiance has been issued by the Board of Health.
Sign d /V'CAl/ Date.: ! D
Inspections
No. (;W l � l U � 'FEE � _
C®�9[�' ONW L111 ®F/�9�[jASSAC14 SETTS
Board of Health, ,° ,7�Gt�C//� MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Andividual Component(s) ❑Complete System
The u e signed hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( Upgraded ( ),Abandoned ( )
by:
at 4-7) C0 Lu ra)bi 4Autn(A Q.. , M K Y S S
f
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application Na. ` c70Li' dated 17/011 A7'12� )
ed Design
siign Flown (gpd)
. r.Pl'/14'/t/Installer r 1 11 -�Fr, r //
Designer: Inspector: 1 / �� Date:
The issuance of this permit shall not be construed as a guarante�at the system will function as designed.
it No. )-00 FEE
s COMMONWEALTH OF MZ—SSACHUSETTS
Board of Health o6rn-< I fi-b MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
' I) Repair ) Upgrade( ) Abandon( ) an individual sewage disposal system
at `>`f) ( ���/ /J/�,� 7`�"V��t�tX_ �j v5 t �S I ( l' /C, as described in the application for
*Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the da e of this -• i . All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date / D�Board of Healt i
t 1
r a o
Town of Barnstable
oFTHE 1p� Regulatory Services
Thomas F. Geiler, Director
* BMWSTABLE,
9�A MASS.9 � Public Health Division
'fD"A0'�A Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 3/23/04
Designer: Shay Environmental Services Installer: Roberts Septic Service
Address: 34 Thatchers Lane Address: 5 Trenton Street
East Falmouth, MA 02536 Yarmouth, MA
On 3/22/04 Roberts Septic Service was issued a permit to install a
(date) (installer)
septic system at 43 Columbia Drive, Marstons Mills, MA based on a design drawn by
(address)
Shay Environmental Services dated 3/12/04
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than IF lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
(Installer's Signature) CA M
' 181 ,
(Designer's Signature) (Affix ere)
tirulTaRXa
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DI CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q: Health/Septic/Designer Certification Form
r
S%u - 20- 01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304
' srzs:o�
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PERCOLATION TEST AN7D SOIL EVALUATION EXEMPTION
FORM
hereby certify that the engineered plan signed by me
�r;eC O , concerning the property located at
43 � bc���•� M• AM S meets all of the
ict:o�4•�n; c;�teria� .
• This failed system-is connected to a residential dwelling only. There are no
or business uses associated with the dwelling,
The soil is ciass:t:ed as CLASS l and the percolation rave is less than or equal to
7t:nutes per !nch. The applicant may use histancal data to conclude this (sc: or may
:onduce �re:imtnar% tests at the site without a health agent present
• There :s no incre;,;e to flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will no( be located less than Foun een
fee; aonve the maximum adjusted groundwater table elevation. fAdiusc chc
7rnunc!• wc- cable using the Fnmptor method when applicablel
Please complete the following:
Grouno Surface Elevation (using GIS information) �®
B,` G.VY' Elcvar.or, _�� cdiuscmenc for 'nigh G.W. Z4(B
>FTT.REN(_F BETWEEN and B
S.G. rED DATE.
3ascc .sort tre atove information, a reoaic permit wil! be issued for beds^ores
:No add u::nal bedrooms are authorized to (he future without engtncerec
=sy.tem plans. --- — .
�r:un:r,:Oci �c�ccamp
' Permit Number: Date:
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: �3 l t�`UMC]IQ. �V'ef1.�� 1-f (�, ��^� Lot No,
Owner: Address: ��-►�►�
v, k Contractor: 5�ttR`� �+Gn evn ��Address: F
_ L\M r-n`tkln NA
Notes: _77
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date 3 �•�
month/day ear
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
0 Appropriate index well.................................................... 5 U3
OB Water-level range zone
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... Amon
CA SC).
/year/year"
STEP 4 Using Table of Water level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water level adjustment
...............................
STEP 5 Estimate depth to high water
by subtracting the water•
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1)
I,
Figure 13,--Reproducible computation form,
15
TOWN OF BARNSTABLE
J i LOCATION �d �'A--_&t�e SEWAGE dp
VILLAGE d ASSES 'S MAP & LOT 1U -W L/
dFL 1��
INSTALLER'S NAME&PHONE NO.
S
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) Z Qf X 37'. Wt
NO,OF BEDROOMS
BUILDER OR OWNE
PERMTTDATE: /.7 d L/ COMPLIANCE .PATE: —
Separation Distance,Between the:' '
Maximum Adjusted Groundwater ble 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.
o
bi
�' A-2i
FAILED INSPECTION 'Si t%(�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP :,� 103
PARCEL ; O 2
LOT
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 43 Columbia Avenue
Marst6ns Mills. MA 02648
Owner's Name: Lisa Fournier
Owner's Address:
Date of Inspection: February 24, 2004 RECEIVED
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford MAR 4.3 2004
Mailing Address: P.O. Box 49
Ostervllle,MA 02655-0049 TOWN OF BARNSTABLE
Telephone Number: (508)862-9400 HEALTH DEPT.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15—W of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs her Evaluation by the Local Approving Authority
✓ Fails
Inspector's Signature: Date: February 25, 2004
The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and 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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 43 Columbia Avenue
Marston Mills. MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or ,
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined", please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 43 Columbia Avenue
Marstons Mills, AM
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
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Page 4 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 43 Columbia Avenue
Marstons Mills. MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
D. System Failure Criteria applicable to all systems:
You mast indicate either`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 '/z day flow
_ ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ An onion of a cesspool or privy is less than 100 feet but eater than 50 feet from a private water
Y P P� P �'Y 8r
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
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.
4
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Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 43 Columbia Avenue
Marston Mills, MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria,related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 43 Columbia Avenue
Marston Mills, MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): 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) ,
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 2121185-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Avenue
Marstons Mills, MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 2"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30" r
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. Recommend
pumping.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Avenue
Marston Mills, MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: --
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.):
The D-box was under water. Liquid was backing up from the leach pit.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Avenue
Marstons Mills, MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -4'x 6'(600 gal.)
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.):
Liquid was above the inlet pipe and up to the top of the pit. The leach nit was in failure. The bottom to grade was 7'.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
• Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Avenue
Marstons Mills. MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
0
0
O
3
.3 33 S8
10
� r
Page I 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Avenue
Marston Mills, MA
Owner: Lisa Fournier
Date of Inspection: February 24, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was 7. Using the Barnstable topographic map and the water contours map. The maps
were showing approximately 25'+/-to groundwater at this site.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed,written or implied,relating to the system, the inspection and/or this report.
11
Commonwealth of Massachusetts
Executive Office of Eliviromnental Affairs
Dept. of Environmental Protection
One winter Street Boston Ma. 02108 Jolm Grad
' D.E.P. Title V Septic Inspector
P.O. Box2119
.Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -��
CERTIFICATION
RECEIVED
Property Address: 43 Columbia Av.Marstons Mills Address of Owner:
Date of Inspection: 10/8197 (If different) OV I �. ( 1997
Name of Inspector: John Graci Shelley Pocknett
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) HEALTH D�PT.
Company Name, Address and Telephone Number. TOWN OF eAFo��'i�,�LE
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria defined In Title V
Conditional) P code 310 CMR 16.303.My findings are of how the system Is
Y sses performing at the time of the Inspection.My inspection does
_ eeds F rthe Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
is septic system and any of Its components useful life.
Inspector's Signature: Date: 10113197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
= Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 0 Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 43 Columbia Av.Marstons Mills
Owner: Shelley Pockneft
Date of Inspection:1019197
— Sewage backup or.breakout or hioh.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C FURTHER EVALUATION IS REQUIRED B] Q D Y THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS 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 of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
— I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to on overloaded of dogged
cesspool.
SAS is in hydraulic failure.
(revlsedO 27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 43 Columbia Av.Marstons Mills
Owner: Shelley Pocknett
Date of Inspection:1018197
D] SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last-year NOT due to clogged or obstructed pipe(s).
— — Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
— — Any portion of a cesspool or privy is within 100 feet of a surface water.supply or tributary to a surface water supply.
— — Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
— _ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
i
(revised OW2A87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 43 Columbia Av.Marstons Mills
Owner: ShelleyPocknefk
Date of Inspection:1019197
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)j
(revised 0QV9T)+.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 43 Columbia Av.Marstons Mills
Owner: Shelley Pocknett
Date of Inspection:70f8197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3m g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings. if available(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nta
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nra
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last year.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nra
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
13 years
Sewage odors detected when arriving at the site:(yes or no) No
peviaed 04127l97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Av.Marstons Mills
Owner: ShelleyPocknett
Date of Inspection:1018197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 0"
Material of construction:x con create metal FRP Polyethylene_other(explain)
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le'6••H5•7^w4•10^
Sludge depth:6"
Distance from top of sludge to bottom of outlet tee or baffle: 20"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: ts^
How dimensions were determined: Measured
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.)
Septic tank and all components are structurally sound.Recommend pumping system now and then maintalned every year.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rva
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rda
Date of last pumpingnl,
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.)
rda
4i
BUILDING SEWER:
(Locate on site plan)
Depth below grade: v
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line?°-
Diameter: 4"
110,mments: (conditions of joints, venting,evidence of leakage, etc.)
(revlsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Av.Marstons Mills
Owner: ShelleyPocknett
Date of Inspection:1018197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rva
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nra
Capacity: rya gallons
Design flow: rda gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nra
I
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level Wth bottom of pipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
The D-box Is structurally sound.D-box had solids In It
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
nra
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 43 Columbia Av.Marstons Mills
Owner: ShelleyPocknett
Date of Inspection:10I8197
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits,number: IPW gallon leach pit
leaching chambers,number:Na
leaching galleries, number: rda
leaching trenches, number,length: nla
leaching fields, number, dimensions:rda
overflow cesspool,number:nia
Alternate system: Na Name of Technology._Na
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit Is structurally sound.It was 3M full,it had solids In h.
CESSPOOLS:_
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: Na
Depth of solids layer: rda
Depth of scum layer: rda
Dimensions of cesspool: Na
Materials of construction: Na
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Na
PRIVY:_
(locate on site plan)
Materials of construction: Na Dimensions: Na
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na
(revised WNW)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
43 Columbia Av.Marstons Mills
Shelley Pocknett
1018197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
�P 13wc k �
Ab
Ao ��
�� 3a
(revlsed04)27197) Pape f of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
43 Columbia Av.Marstons Mills
Shelley Pocknett
1018197
Depth of groundwater
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised04r27197) page 10 of 10
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct (\A or Repair an Individual Sewage Disposal
System at: VV
Locatio -Address or Lot
Owner
'40 Address
��� Address
PQ
T�c � S�� �� Sq. feet
Dwelling—No. of Bedcoonoo----'~°�-----------_-' Attic ( ) Garbage Gc6z6�r ( )
Other—Typeof Building ............................ No. c6 persons............................ 6bm°ecs ( ) -- Cafeteria ( )
Other fixtures .................................
-` Design� Fln�-' / � �� Total per day. I ` Q'
04 Septic Tank--Liquid 1PR.0gaDnua Leoctb-!R.L(?.' l�idt6'�t����.. D�o`c�r------.. De����.���-',
DisposalTceoch-- --' Totu u ....................�� �tbTotal leaching area.......... �q 8.
Seepage Pit I�o....-I--'.-. D�ozetcc--,���'�-' Depth below inlet--����--- Totalleaching urou',�&z���og. 6.
Other Distribution box
Test ��
Percolation I � l�eool ' Performed ' ����. _ Dute--'S--)k'��-��'��'
Test Pit No. ]-!��'odoutoa per inch Depth of Test Pit-- Depth to ground water.....���..........
�
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---_-. -------_'-----_-_
0 Description of j5
-------.--_---_.----.---.-.-_----------.----.----------'----_.-.------.----.--------'----..
U Nature of Repairs or Alterations--Answer when applicable-.............................................
-------------'---------------'--------'----------------''-'------'-------'-'--------'-'----
' g'____.
The undersigned agrees to install theuforedescribed Individual Sewage Disposal System inaccordance with
He provisions ofZ[TL IZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued
------' '--- �
Application- - --��'-.-- _ �'-^'^-_'r^-���-------
~=
| Application Disappr r the following reasons:...............................................................................................................
_
� ------------__-......-----_--___---__'--_'_------_---'-'--------_-------_---'----_'--'----_-'----
��
L'te I
' ' /
i
No.:`.-------•=-=-•---- Fss..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applirattion for 14spogFal Works Tonitratrtion ami#
Application is hereby made for a Permit to Construct AA or Repair ( ) an Individual Sewage Disposal
System at: _
..........»( O-t U Y�U -------•.AV rw.-.... ......................... .
Location-Address _or Lot No.
.... .»........ ..................... ......_.........._....... ... ....
Owner Address
Installer Address
Type of Building Size Lot..�0........ ....Sq. feet
Dwelling—No. of Bedrooms......... ...............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building .... No. of persons............................ Showers — Cafeteria
Q' Other fixtures ---------------------•--------------------------------••-••-......--•---.
Design Flow......... ... .......................gallons p&:pe:ek per day. _Total daily flow...........v � gal
WSeptic Tank—Liquid capacity.i C C-Ugallons Length._a':.1._' Width.:!-..'.!()...I Diameter................ Depths
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter......J._;�.....:--Depth below inlet...... Total leaching area.._%!�A..sq. ft.
Z Other a
� Percolation r1Test Results ) Perfo#me yin- # ��A - ••------ - )r' le).a.------.. Date-----.
Test Pit No. 1___._...__Z__m>nut�es pnch Depth o£l Testy Pit.... Depth to ground water.___-"`"-__-_-.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------------------------------------------------•-••------•-•------••--.........................................................
Description of Soil--C-'- -.... . '..........................
...........:�°" . 7 U'�-' 'a ;` -- -----------------------------------------------
chi ---------��` ----•---�`a_c -„----•I:x� 17, 'f .� 1`� !�` T .: ._._. -.y -v :....
W --••••••--••---------------•-------•-•----•----•-•-•---------------••-•-•-•-••----•-•---...•-••-....------•---•-......-----•-••---•••-•---••---•••-••--••••••••-•-•-----------•--•-----•----•-••-------
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
.......................... -----------------------•----------------------------------•----.....................-------------------------------------------------------------------•-••-•-•---------••---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
>gned•••.......-..••-_==-�'='=_ :----------------------------------------------------------
Application Approved I ':= •--=-•----•.....................................•----•-•-------------•-•-•--•-•--•---.----- � =
Application Disappror for the following reasons:.........................................
-------•-••..................................••---Date
...........................•---------..............------------------------------....---•-------.......--.•--------------•---------------•-•--••••-•---•--------••------•--•-----•-••----•••--•----------
Date
Permit No..---..... ------------------•••----- Issued-.........IJ......l- ....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
�rdifirate of Toan�rliFatta
T�iS °S TO CERTIFY, That the Individual age Disposal System constructed ( or Repaired ( )
by-, ...:.....,....._..... :..._.. -1 --------..•..------------....-----•--...............--•--•-----...-----......-••--•-----..._..--••--
-' Installer
has been installed in accordance with the provisions of TI.TI, 5 of The State Sanitary Coe as de i d in the
application for Disposal Works Construction Permit No.Z,.../,/�................. dated..... ... / ..... .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... �......-�......�.....--------•---•---•---- Inspector..... -� --•--------------------•--------.-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NO. ��... ...........................................OF..................................................................................... Za,
.... ............................................ EE
Dilly,0461 orko wonstr ion amit
Permission is he t d_...r. c .._.....
to Construct �0 air ( ) ar '1nd' idua ewage Disposal System
at No...............'"i.. !�' •--- - ..�...... ....... -Street � 17� 4..........
as shown on the application for Disposal Works Construction Permit No.9.1-4_1.... Dated......... ..............................
-••-----------•----•-•------------- -- _
rdFIea
DATE------..IJ-•--- -------------------------------------
FORM 1255 A. M SULK•N, INC., BOSTON
r
20 FT, MIN.
TOP OF FOUND.
L, EL, _
. r to FT MIN.
Y CONCRETE 4„ I SCH. 40 PVC _CLEAN SAND
.. . _ COVERS
PIPE MIN. PITCH
CONCRETE
I,/8 PER FT. COVER-
. .
t :.
2'� L.AYER OF
4 CAST IRON 1211 MAX. I/8"- Il2�� WASHED
r4�f PE N, FTTCNSTONE
a 46
71
FLOW LINE z
rto
x L _ {
1
E - -
MIN, -_ .� _EL
EL.
i = a EL.= °
EL,_
DI ST. EL. a 41.
ILLI
� .
LO'GATION MAP �� BOX sb°�6 " -
3/4 - 1 1/2 C °. J I
WASHED STONE oUo i
-y, e
i
PRECAST LEACHING
GAL
BASIN OR EDUIV..
ti.
SEPTIC
� ` TANK
,
GROUND WATER TABLE EL
PROFILE OF :
SEWAGE DISPOSAL SYSTEM
4 , NOT TO SCALE
4 DESIGN CALCULATIONS
SOIL TEST
' # NUMBER OF BEDROOMS .. . . .. . ... . . . . . DATE OF SOIL TEST
i
GARBAGE DISPOSAL UNIT- - - - - -,
; WITNESSED BY G
TOTAL ESTIMATED FLOW
4 ( PERCOLATION RATE_.__ MIN,/INCH
L ?'at /BR./DAY x BR. ) . . . . . . . GAL /DAY
- OBSERVATION HOLE i OBSERVATION HOLE 2
-)-Pj IC TANK CAPACITY..., . . ... . GAL.
j
:•' " GAL. ELEVATION = t 7 r ELEVATION
ACTUAL OF SEPTIC TANK,-. . ... - , ..
LEACHING .=,REA REQUIREMENTS
} Z
_ . I "' • ' SIDEWALI,. AREA ;' - GAL:/S.F.
-z -_ BOTTOM AREA GAL,/S,F,
-_ LEACHING CAPACITY ( BOTTOM + SIDEWALL), M' GAL.
n
•
• '�... ,;� r. � -- __ RESERVE LEACHING CAPACITY ... .. ' 2 2 GAL, �
i
NOTES
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM
TO D,E.Q.E. TITLE 5 AND THE TOWN OF -
RULES AND REGULATIONS , FOR SUBSURFACE DISPOSAL
OF SANITARY SEWAGE
2.COMPLIANCE WITH ZONING ` REGULATIONS SHALL BE
DETERMINED BY BUILDING INSPECTOR OR BUILDING BUILDING SETBACK REGULATIONS PER BUILDING
COMMISSIONER INSPECTOR OR BUILDING COMMISSIONER
&EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY MIN. FRONT SETBACK
MIN. REAR SETBACK
THE SAME
I t
MIN, SETBACK.
SIDE..
y .
APPROVED : BOARD of HEALTH
_
�zr DATE AGENT
PROJECT LOCATION
APPLICANT :
LEGEND
SCALE: DR. BY: DATE;
EXISTING SPOT ELEVATIONS OOx0
J08 N0: ,. ,..- APPD. BY: REV.
EXISTING CONTOUR - - - 00-- - - - ,: ,_ . `.. ,.: _.. :•:
FINAL SPOT ELEVATIONS 00.
FINAL CONTOUR ----t00 i /;f,f R. J O HEARN, INC. DRAWING
SOIL TEST LOCATION % /r 1f % =�/ REG. L AND SURVEYORS- REG. SANITAR/ANS N O.
• ;
a 348 RDUTE /34 - P.
S D. BOX
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1
SITE PLAN EAST DENNIS , MASS. OF
SCALE ,- `'
F'ECTION A -A
*NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. ALL OUTLET PIPES FROM THE
10' min. from PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DISTROUTION BOX SHALL BE
SET LEVEL FOR AT LEAST 2 FT.. 12" -- -,CONCRETE COVER
ExIstN Foundation �h..Se to septic tank I
Septic tank covers must be 3' of 1/8' - 1/2" Washed Peastan
Top of Foundation ELEV. IODA (Assumed) within 6 in, of finished grade -3/4" to 1 1/2 " Washed ed Stone 2.
Grode over Septic Tank 98.00 Grode over D-Box 9&50 ode over SAS 98.50 3 5" OUTLET
KNOCKOUTS t
12" INLET 4' PVC (CAPPED)INSPECTION PORT TO BE
INSTALLED AND To BE WTHIN 6' OF GRADE OUTLET
7------------ LA
S
0-02 3 HOLE H10 TOP Load EWv. =96,75
DIST� BOX 3' Maximum C�ff 'a'
2
SfO.01 or Grecter --Top of SAS - Bev. -96.25
12' EXIST.
FXIST. PIPE 1,000 GAL. S- 0,01' per foot A
(D 10' _10" Effective Depth
FRC04 EXIST. F"DATIIIN SEPTIC TANK 'Al
Cn H-10 OD 2 625' 30' PLAN SECTION CROSS
It saft
3'
1 CONCRETE FULL FOUN 0,83' (10 inches)
> 31.25'
3_725'--
0 3 HOLE H-10 DISTRIBUTION BOX
Z if
51 6 in..f 3/4"-1 1/2' 7
SYSTEM PROFILE 0) Effective Length NOT TO SCALE
compacted stone _40 �2.5�
Not to Scale 4' 4' 11 SOIL ABSORPTIDN SYSTEM (SAS)
5
W INFILTATROR HIGH CAPACITY (H-10 LOADING)/ GEORGE O'BRIEN GENERAL NOTES
6 in.of 3/4'-1 1/2' 4) _@
compacted stone Effective Width
(OR EQUIVALENT) Not to Scale 1. Contractor is responsible for Digsafe notification
NOTE: ALL COMPONENTS MUST HAVE 0 RISERS TO WITHIN 6" BELOW GRADE Bottom of Test Hole 1 Elev.=86.50 as NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18* /EFFEC_nVE HEIGHT IS 10' and protection of all underground utilities and pipes.
2. The septic tank and distribution box shall be set
vObs. Groundwater Test Hole 1 Elev.= NONE OBSERVED level on 6" of 3/4"-1 1/2" stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
by Carmen E. Shay, - Environmental Services, Inc.
5. The contractor shall install this system in accordance
with Title V of the Massachusetts state code, the approved plan
PERCOLATION TEST and Local Regulations.
LOT #70 LOT #69 LOT #68 6. If, during installation the contractor encounters any
Date of Percolation Test: MARCH 12, 2004 soil conditions or site conditions that are different
Test Performed By. CARMEN E. SHAY, R.S-, C.S.E. from those shown on the soil log or in our design
Results Witnessed By: WAIVER (per BARNSTABLE B.O.H.) installation must halt & immediate notification be
Excavated By.ROBERTS SEPTIC SERVICES, INC. S 85d 56' 00 E made to Carmen E. Shay - Environmental Services, Inc.
Percolation Rate: Less Than <2 MPI
7. No vehicle or heavy machinery shall drive over the
130.00 septic system unless noted as H-20 septic components.
8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
Test Hole 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
No. 1 10. All solid piping, tees & fittings shall be 4" diameter
DEPTH SOILS ELEV. LOT #59 Schedule 40 NSF PVC pipes with water tight joints.
0 98.50 11. Municipal Water is Connected to ALL OF The Residence and Abutting
Sandy 20,800 Square Feet Properties Within 150 Feet.
Loom
10 YR 3/2 THE PROPERTY LINES ARE APPROXIMATE AND
_6" A, . 800 COMPILED FROM THE SURVEY PLAN GENERATED BY
Loamy TEST HOLE #1 EDWARD KELLOG, C.E. of OSTERVILLE, MA
Sand ELEV.= 98.50 O ENTITLED - "PLAN OF CONNECTICUT VILLAGE IN M. MILLS, MA
10 YR 5 DATED NOVEMBER 1960, PLAN BOOK 157, PAGE 97.
6'- 36" B. 95,501 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
filak O co
Med. IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.Sand ......
25 Y 7/
'
1 4
36'- 144 C 0
EXISTING LEACH PIT TO BE PUMPED OUT AND
EXIST. SHED FILLED IN PLACE.
NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
FROM THE EXISTING EACH PIT TO BE DISPOSED
LOT #58 25' Failed LOT #60 OF AS PER BOARD OF HEALTH SPECIFICATIONS.
LEACH PIT NO WEI_LANDS Atli PRE iENI_ wiiHIN LOU' 01 IHE HHOFERiY
Septic Tank
98- DECK ASSESSORS MAP 103, PARCEL 024
Perc #1 LEGEND
Depth to Perc: 36" to 54" HOUSE #43
Perc Rate= Less Than 2 MPI
44 DENOTES PROPOSED
Observed ESHWT@ - NONE OBS.- 144" Assumed - EXISTING F-04 X 11 SPOT GRADE
ADJUSTED H2O Eiev. NONE OBS. - 144" Assumed 3 BEDROOM
HOUSE DENOTES EXISTING
(Z X 104.46 SPOT GRADE
kn
PL
PROPERTY LINE
GRAVEL PROJECT BENCH MARK ___--49 6P PROPOSED CONTOUR
DRIVEWAY
TOP OF FOUNDATION - - - - - -97 EXISTING CONTOUR
ELEV. = 100.00 (Assumed)
k DEEP TEST HOLE &
2-18" DJAM. ACCESS MANHOLES
PERCOLATION TEST LOCATION
6 FOOT 'STOCKADE FENCE
f
INLET
ou-n ET
I ,
THE ACCESS COVERS FOR THE SEPTIC TANK, 130.00' P I OT P LAN
DISTRIBUnON BOX AND LEACHING COMPONENT
SET DEEPER THAN 6 INCHES BELOW FINISHED ------- -----------------t 0 F PROP
r'-I-.f7_- PROPOSED SEPTIC SYSTEM UPGRADE
GRADE SHALL BE RAISED TO WITHIN 6' OF
FINISHED GRADE. S 85d 56' 00" E
STEEL REINFORCED PRECAST CONCRETE 98 PREPARED FOR
PLAN VIEW INSTALL TUF-TITE GAS BAFFLES OR EQUALS
MS . LISA J . FOURNIER
3-24' REMOVABLE COVERS AT
I /_ I U 0-,L LTM�"_TA A V_E7_�V t,7-,V
4- #43 COLU 'IV'IBIA AVENUE
7
3' min. clearance
. I - is" INLET
INLET n�. 8' m_1n_.T_12" min. inlet to outlet . , - ._I I
min. OUTLET MA
(40 FOOT RIGHI OF WAY) MARSTONS MILLS ,Liquid level
Tr._r outlet in I.-rnin. F
5' -7-
5' -7-
Design Calculations
E� -a' min, OF 14,4S,, PREPARED BY-
Liquid d 0. R." depth
Numb 30 Gal. Da (330 Gal. Da V,n. per Title V)
Number of Bedrooms: 3 Equivalent to 3 r A)?JIEY E. S_[JA Y
Garbage Grinder: No
jI Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V)
0 ENVIRONMENTAL SERVICES, INC.
a* 0 20 41D 50' 0 Septic Tank 3 x 330 Gal./Day = 660 4' -ICr-1 USE EXIST. 1,000 GAL. '.optic Tank.
CROSS SECTION END-SECTION SOIL ABSORPTION AREA: Using percolation rate of <2 min./in& 0.
Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. 273.8 c P.O. BOX 627
Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons. EAST FALMOUTH, MA 02536
TYPICAL 1000 GALLON SEPTIC TANK Providing: = 331,80 gallons SCALE: 1 "=201' ANITAP,\ TEL/FAX : 508-548-0796
NOT TO SCALE Use: 5) INFILTRATOR HIGH CAPACITY H-10 UNITS, HAVING A 0.83' ('10 INCHES) EFFECTIVE DEPTH, SCALE 1 "=20' DRAWN BY: CES DATE: MARCH 14, 2004
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE PROJECT#SD535 FILENAME: SD535PP.DWG SHEET 1 OF 1
ON THE ENDS. NO STONE UNDER. --------