HomeMy WebLinkAbout0114 COLUMBIA AVENUE - Health 114 j
LUM BIA AVE.
TONS MILLS
3-009
Y
9
Title 5 official Inspection Form 5
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,Ry I
114 COLUMBIA AVENUE
DOREY, SUSM E
Owner Owner's Name
information is '
required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
to !r#i rasa r lts,mmktst be sluhmAfted On this form_ fosn s.may nat be attp5pd t"Rny.
way. Please see completeness check ist.at the end of the form;
Important:When A. General Information
filling out forms 51 (off
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Robert Paolini
use the return
key. Name of Inspector
17 Playground Lane
Company Address
Yarmouthport MA. 02675
Vllyl i-VWi Ll)i LAC
508 362-3555 $14454
Telephone Number License Number
B. Certification
1.�.eri fi,l i 6 �.�?u a n rertniiii.A Y,�'n�nte]fi-*ke,Se,.,,N^0 rlianncni o.ArJ,tnm at this �r:eiress anei '�'A�h4 Y'nef
I la [ 1 A i 1 Y.4 iAJVAii1 A.IY II 1✓lii.Ail V.U 31.. vVY. j lA J`.f VtJaii J lVll i IIJ Gi�/.d ii J 41110 l 1 l U-iV
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:
C .Pss�s D !^onditinnallu Passes I l Fails
❑ Needs Further Ev uation by the Local Approving Authority
4/10/18
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 con+ditions 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.
'1'�iii[3•i±iii' ifue.`i offi iai ii is}iECuo A Su-bsudIaiz Se mp Dispvsui:.Syaim,:-Page i.of 117
COMMO"Weafth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,•''� 114 COLUMBIA AVENUE
�ope��ddr�s
DOREY,SUSAN'E
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Li 13pGNion summary. "l, ede1 A,S,Cjt`or E.i alfw ays co^lplete Gill til%S e-ii Vl l ii
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
!r 6cated bejo 1!l.
Comt tints:
B) 15y'stern Cond itiional!'y`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"yeys", lino" or"not determined" (Y, N, ND)for the following statements. If"not
UVtVrmif iV�,��iLS�.iJ�i Gix�IGit1 6.
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.
I} tal se"-4-1, ill -ssinspection if i c ll y sp ' nid ok i� iei nerd + '-�s'iiMlr+2rpp G+i
{"�IIiGtGI JLi./tIV[GI ir\YYilt pGJJ 11 it structurally ally JV\f 1-IV,v nW[.Iva(\rng.;GI'IV Ir G.Vvl[fliNaa[4 Vi
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
15ins-11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,. 114 COLUMBIA AVENUE
Prnniarh;,4.ddF?xv
..,._..'
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Sys Wiii t Wiiddftnafly`
❑ 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):
1=) brake na�nrn/S')ara r�r�.a-rl M Y n JJ 0 ,ND I Yplain belowf:
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
u The system required pumping l ore tha t 4 urr es a year due to rh oken 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):
r4 'Fue'ther KEV"--lu&:n l-Required
by 411-T �Board of.-�:ealIth:
❑ 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,
-safewty ansJ the enviraanment.
❑ 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
Gornmon-weal"' of 1"Y'lassachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
114 COLUMBIA AVENUE
i3r�rrs+t'njt�sfrsrt?es
DOREY, SUSAH E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. Cityrrown State Zip Code Date of Inspection
B..Certification (cost.)
B i c,4.i��L�yL{<rasi 'i f�..i o H,p il�.s�so LILw—i4"ils A 0-11''v-10.1at :LLn.yi= �.
b� fix�Ti6m YV LL[.fC.�f liF ilG3 �:ti'i bYV�tt V VL L L64LLi4 t,Cf.i L YLJLt4'HHi}.6F�r WctY d tLfbf 7....L.iyI
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 .
❑ 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:
sb :pia darn n cap lit trxa csil w aatn analysis,y sisJ n4rfo,---d at a �1E D. n-r finei laboratory tnr on i-
I 1 IIJ S.- (f p/ JJ J 11 t((4r V-11 YF l 121 "yJf ,,FL(± (11. i 6J tel 4lr(tli iyt, j�{y-Gk GlkFi�i,
conform 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) myateLsn sbstitai �r'LtertL��wpav'skii s€.v All �' n'L :,
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
n R1 Backup of.sewage into facility or system component due to overloaded or
CIA 0T cessp3
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ 0 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
❑ 0
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
�`�'smi i3�`aw-eat `t or i s ,aa�a ea
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
SvO,r 114 COLUMBIA AVENUE
-S"srnneri,i iririrwe:;
DOREY, SUSAN E
Owner Owner's Name
information is Marstons Mills MA 02648 4/10/18
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ ❑x Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑x ❑ 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
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with i no acceptable water,qualify analysis. t i his
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.]
Q�4` C°trL?�I can .ten o ttnif 4a
a 4n Yiprir}n tP�.Ar rea �(ii Ntnii=
SP ,....,,._ ...
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
ZZ 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.
a=i Large:.:.rEigsr. 31` ..�g.�nm :r$gret3 lame ciem a w r -,+- v wa:rrP serve.
_ f '^�-.� �....<„a�aa ,3e:�s:ar.e -��,Via. � ,r �p.at ... .�ffir.ap..�
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 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
14 i_i vu€}tlYe GI�J Vlf. 4,e4.! M....`S L4J' 4f;aueJl1i^!F�in s-.r..�oR}i_ U€Y'.JV.7fiV}kk i }SfkAG3 1k @ skin ii4caift 11}Teel..
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
4 i Cumiiiu6 i%educh Chi iviidti5d(:huset-i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
114 COLUMBIA AVENUE
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
C. Checklist
5.ccn .ions V....�. ...4 �n:d�....b+'.'i - - .. F.� ..� r�o-:.��.�si....��.,_
's.it iLlrii ii viiUty st i� t iii r is U.Ji iir. a iru eceidda�i li iUeiiCa i'v pvJ ✓. ..v �J iv�Cl iii i �. i.Fii iveii/v5 it i�,_
it iv
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
1J1 M Wene aRv.nf,the s.,-tem rnr»nnnantc ni im�niad ni it in tFi Qnrcefin)is tWun c�tgek ?
❑ Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built,plansof the system obtained and examined? (If they were not.hh
zva�b
0 ❑ Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
v vci c ti i-G zovyui-:Ical im 11 lal li iV icy U!ILAX cl CU,VPW MV, a)lid U 10 if i=ci ivi vi si is KU M
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
0 ❑ 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
b.rar.r.:dni n::aa:vanr43�nr•n€ti rari..
0 ❑ Existing information. For example, a plan at the Board of Health.
0 ❑ 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 Intormetioln
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESiGw flow based on 31 u Cn1i 15.2-0-3 (for exampie: i l u gpa x;F or oedrooms):
aci w.-a ra.n re oigy !Sf«'--age6of 17
-
�� 4(9AOi6i116iF1��C[�lfi Cll i�����C'�:IiiT.BS��CS
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
114 COLUMBIA AVENUE
`vrnnaifi!aa�vrirncc
DOREY SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
D. System Information
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑x No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No
i .. ....A.,.. .. - ....i...J/1 !Vi W__ !i! AYE... ....a T.....1 :.���.
• i-di.ii ivi� Ski Si�ci Ci ii aS�cGici.i_i u i c u iev
Seasonaluse? ❑ Yes ❑O No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
--------------
Sump pump? ❑ Yes No
Last date of occupancy: • •
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
i'Snoinn si,-.:s i; �rnri n»=H I f-SAivvv:+ 9 r O I i• ---- -_--.
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
`I Grease trap present? . ❑ Yes ❑ No
- tqq
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
4`',l� �+Uif111lij1iril�.'Cfi�I1 (!F IifiQ�S�Cif1�Ae$�d$9
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
" 114 COLUMBIA AVENUE
P,, rVy n,srirncr
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ YeC FRI Nn.
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
n 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 uur t dui(iu ue uu aii Feu irum system uvvi e )anu a uuiiy Ul 1UR161
inspection of the I/A system by system operator under contract
❑ Tight tank: Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
114 COLUMBIA AVENUE
DOREY SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
RuilFli q Sewer tloCate on Sife plan):
Depth below grade: 1.5'
feet
Material of construction:
❑ cast iron ❑ 40 PVC 0 other(explain):
Distance from private water supply well or suction line: "
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.System vented through the house vents.
' yv�✓aa'v i�Gvaa-�i�sv�ev"vi i�.iv P.iv�J.
Depth below grade:
16" �
feet
Material of construction:
Ix_—i concrete ❑metal I l fibernlagc ❑nOlvoth�rlgnsi i £}tho;(cla„lin\
I
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
2"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
LU6IIr71urlwl dKill UI lviCi3baurlubell
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
114 COLUMBIA AVENUE
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
33"
1„
Scum thickness
711
ristance frnm too of sc-tirn:tn t»»»f n�itic!_tee.or,haff e
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
trnr�tr'I,lc<rotq�q,ral tonl,Fn•_r» }tot sr»sor4. evirl ^F to., ls�np �{•�L:
Pump tank every two years.Inlet and outlet tees are in place.No evidence of leakage.
Depth below grade:
feet
Material of construction:
I�rnnCrQtn 171 F1 fiharnlacc R ninilirc#hvlpna 0 other{QyrDlainl-
Dimensions:
Scum thickness
� Jaix v�i ri:J vvawii av aL t.i v vaAaivi aVvLi vai.iv
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Uf Iv dWid( fiubeu5
Title 5 Official Inspection Form
F a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
114 COLUMBIA AVENUE
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
-
..i.:iii:ii��..: �...:Yu.::r.i.� i ..aJi{.i..ia...0 i:i.{. it rli•m..: as:.. .... ..... .. .iu ...\.cs:i.aiwi , ..::v:ia:.�. ....i:�'::~f`,
liquid levels as related to outlet invert, evidence of leakage, etc:):
i.� -G Ji i iiii aiii �'K •e `14n...\Ii.aaVl ivv i.J'iAi..r.lV a.i wi• •..�iv v.-il iVi.3LV�.V ./ .vvuw�V v{{V.\V r.V+{ .
Depth below grade:
Material of construction:
1=1 concrete 171.nnetal; E fiberoja n 1-1 other to—YLHainl;
Dimensions:
Capacity:
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date
Comments (condition of alarm and float switches, etc.):
h LLUU1 i wl./y Ul Wl i tri n PUi i iNil iy UUi U dGi ti t:lLlUll UU). Ia UUPY ditdU iidU r
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
W--offifflut1wei1.-i<fi U1 1ti1d55di:11u5eU5
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i 114 COLUMBIA AVENUE
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
iii°iiiia Kiiinii -'V +��— YJVi[i iiii.iJl wiV V liVin' - V[..i l'v Vi[ J[iV aii"
Depth of liquid level above outlet invert no
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet Iateral.No evidence of leakage.
vo--'c—'is isi i:nil:}Jiui j.
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
rnmmantca(nnta-rnnrtitinn of,ru.imn n.hnmhar rnnriitinn of ni imnc nnri anni irtananrac atr \-
.;Final :e-P:vvvi`.ba`i
If SAS not located, explain why:
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 114 COLUMBIA AVENUE
DOREY SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
yr.
p leaching pits number: 6'x6'with 2' stone
❑ leaching chambers number:
1par..hinn c1g1lcricc na imhar
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
IJ ii itiUVCllt It�./�iiliritic7iiV�Jy JiZiil .
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc:):
Sandy soil.no signs of hydraulic failure.Pit had 28"' of water at time of inspection.
Y4°3 it.iifG.36v `VVJJ�IV Vi ii1VJi ilV f.iVii iF1VV Uv flUii ill it iv'i'v Vilvii/\iVv4lV Vii JiiV �iiUii/.
Number and configuration
Depth—top of liquid to inlet invert
flan#l1 n#enlids toa1
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
114 COLUMBIA AVENUE
DOREY SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code -Date of Inspection
D. System Information (cunt.)
ii:
etc.):
i —Y %--i-
Materials of construction:
Dimensions
ncnth of gnHeic
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
114 COLUMBIA AVENUE
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
!Vv{�iV U Y:V tlY V! tilt/ a.�V
YY c:a�te u .d.-...e. .�..,... a ate:. ....u�.suuul uy utvls. ii:i.l i.s tell ly tis.•:; ..
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
1 .
i
11/26/2017,7:53 PM
6
isins•11t10 Tie s oftisi WspecWn Form:She Sewage Dissat Sysiam•Page 15 d 17
lsUfilflliii11Wedlill UT 1V1d55dt 1JU5eU5
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.'' 114 COLUMBIA AVENUE
DOREY, SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Q.-a nsa'ea s-
FX1 Check Slope
❑x Surface water
n ---roll--r
❑ Shallow wells
Estimated depth to high ground water: separation from bottom of LP is 15'
feet
Please indicate all methods used to determine the high ground water elevation:
l__J ii Viii JY.Siviii QcQivii pic2ii.7 Vli iaWil.i
If checked, date of design plan reviewed:
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
U'SED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater
elevations.
- - - - _
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t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
114 COLUMBIA AVENUE
DOREY SUSAN E
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/10/18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
u ii lJptvGIIUi I OU11 it 1 ICU y. n, D, V, i.l, UU G(A iCl;htVU
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
0 System Information—Estimated depth to high groundwater
i
LOCATION SEWAGE, PERMIT NO.
VILLAGt`
INSTALLER'S NAME a ADDRESS t
--2 r3 �dL
-B-U-*t*t R ON OWNER
DATE PERMIT ISSUED
SS
f
r
DATE COMPLIANCE ISSUED
1 I
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R41)
Rehm i
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THE COMMONWEALTH F, MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual-, Sew�gi� Disposal
System at:
Owner
'am 00
Installer Address
10
z Other Distribution box ( ) Dosing tank ( )
Test Pit No. I...?��...minutes per inch Depth of Test Pit.....I.3. k...... Depth to ground water......MA...
The undersigned agrees to install theuforedescri6ed Individual Sewage Disposal System inaccordance with
the ov 0 f'LI'ALE 5 of the State Sanitary Code—The undersigned furth r rees not o th i
| � /*pp/u�ovu uf�ovvru oy'-.�-_. ---'^���'��/—�~�----
gt"
Ao�okxt�u� for the reasons:...........
`
--
---------------------------L--L--_— -
41
Fimx.. .5..........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF............... .......I......
Appliration jor Disposal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
system at*
UK6 b 1 6 (10 iA f1i Ave..
........... ...
.....
..................-.-....... w,
------------- /s
IAK+enc� --- w1 Mfi 4196 O
W .;. .......... ................... . ------
ryh
(%noOwner jl� .......... .........
Installer ---
Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
PL4Other fixtures ......................................................................................................................................................
C�
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Ix Septic Tank—Liquid capacity............gallons Length................ Width.........._..__..Diameter---------------- Depth....._...___....
W I Disposal Trench—No..................... Width.................... Total Length.....:_.:::........_ Total leaching area....................sq. f t.
1Z
Seepage Pit No..................... Diameter....._....__.__..... Depth below inlet........._.._......:Total leaching area..................sq. ft.
J Other. Distribution box Dosing tank
.-Pircolation Test Results Performed by.......................................................................... Date........................................
Jt
Test Pit +iql ................minutes per inch Depth of Test Pit.................... Depth to ground water.._._...._.._...:.......
44 Test Pit No. 2................minutes per inch Depth of Test Pit-_......_........... Depth to ground water..__.................._.
............................................................................................................................................ ...............
0 Description of Soil..........*..........................................................................................................................................................
U ..........................................................................................................................................................................................................
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.........................................................................................:......
. .. .......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the oar d-i health.
A
Signw
.................... ... .... ..................
...........
Application Approved By.......... . ..................
............................................................... ......... ...... .............
Date
Application Disapproved for th ollowing reasons..............................................................................................................
.......................................................................................................................................................................................................
Permit No.....
-------------------------------------------------7- IssuIssued................. Date
......................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OFI�........... ...... ....... ..............................
ft
Tiftifiratr of Tomphaurr I
�
That the Individual Sewage Disposal System constructed ) or Repaired
E
b�YQ-W" TVA
.....................................................................................................F......................................
b I u mb.fic) �e)o 5 lq;11�5
--------------*-------------------------- ------------------------------------ ...0.............................................
has been installed in accordance with the provisions'
of TITLE 5 of The State Sanitary Code s described in the
application for Disposal Works Construction Permit No....... .......... dated.......S.-I JRS7..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GU AR4 TEE THAT THE
STRUED
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................ ............................ Inspector........ .............&..t..............
S TTS
THE COMMONWEALTH OF MASSAC SETTS
BOARD OF HEALTH
.........................................OF.................................................................................
No......................
FEE._.......: :.
!or�vw%pns rtwn Vrr lit
5 -" -> ( Lm
Permissio V is hereby granted['. ."......................................... .....................7-&�c.......
to nstfuc ), jan In , al Owl g e - 1 In-
t- UJIT
o �j 6 ���* (/I
CV M �
...............................*---------- ......................9........
at No....
--------------------------------------------------------------
Street 95 it , f
as shown on the application for Disposa1111'Works Construction Permit No------ ...... Dated------------------------------------------
. ....................................... I..........................................
B andof Iiealth—
DATE............................................ ....................
FORM 1255 A. M. SULKIN, INC., BOST'ON
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