HomeMy WebLinkAbout0164 CONCORD LANE - Health 164 &htordiah6.0 �!+
Marstons Milis
A-122-125-011 -
i
Commonwealth of Massachusetts
' 1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name 1
information is Marstons Mills V Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 51Ar- 15aop
on the computer, Brett Hickey
use only the tab y
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return key. Company Name
374 Route 130
ca` Company Address
Sandwich Ma 02563
iL
Cityrrown State Zip Code
(508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hicke Digitally signed by Brett Hickey .
y Date:2021.03.05 14:28:33-05'00' 3-4-2021
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6.
1) .System Passes:
❑■ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
-- , Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
St
page. City/Town ate Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El El clogged
of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
j164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y2 day flow
❑ O Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ n Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ID 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.]
❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ Fx 1 The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone I I of a public water supply well
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
P ' '
Commonwealth of Massachusetts
--- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- 164 Concord Lane
l,•
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. Citylfown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ El Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
❑ E 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?
❑ 0 Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ 0 Was the facility or dwelling inspected for signs of sewage back up?
n ❑ Was the site inspected for signs of break out?
0 ❑ . Were all system components, excluding the SAS, located on site?
0 ❑ 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? i
❑ ❑ 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:
El ❑ Existing information. For example,a plan at the Board of Health.
❑ O Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
�u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town Satet Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 425/GPD
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ❑0 No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2020- 26,000gallons 2019- 146,000gallons
Sump pump? ❑ Yes X No
unknown
Last date of occupancy: Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
i
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq„ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present', ❑ Yes ❑ No
If es discharges to:
y 9
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
p 9
Source of information: Owner- date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
4. Type of System:
0 Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1982 per plans
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
1'6"
Depth below grade: feet
Material of construction:
❑ cast iron 40 PVC ❑other(explain):
�
Distance from private water supply well or suction line: Town waterfeet
Comments(on condition of joints, venting, evidence of leakage,etc.):
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
,- � Title
5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
6„
Depth below grade: 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
1
Dimensions: 000gallons
Q 11
Sludge depth: v
2811
Distance from top of sludge to bottom of outlet tee or baffle
0r,
Scum thickness
NS
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle NS
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�b--
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owners Name
information is Mars-.ons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain):
Dimensions:
Scum thickness
D stance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
NA
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y' 164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
St page. City/Town ate Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0"
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 in working order at the time of inspection.
t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 3-4-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
NA
* If pumps or alarms are not in working order,system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
)
El leaching pits number: (1 6'x6' pit
❑ leaching chambers number: .
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
El overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leach pit was dry when viewed
r-
with no evidence of past backup.
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. 164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
cam, Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Concord Lane
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
St
page. City/Town ate Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
Y
Ddve*ay
Rear
B, A-
Deck.,
3
Al.3V 81.26'
A2 37 MIT
A3-I.T
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
p Y
t
j164 Concord Lane
Proparty Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/—own State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
K Check Slope
■❑ Surface water
❑■ Check cellar
❑■ Shallow wells
Estimated depth to high ground water: No GW @12'feet
Please indicate all methods used to determine the high ground water elevation:
'❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 7-30-1982Date
❑ 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:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
- 1
Commonwealth of Massachusetts
r
Title 5 Official Inspection Form
� Subsurface Sewa
ge e Disposal System Form -Not for Voluntary Assessments
9 P Y
ry
f 164 Concord Lane
�M1
Property Address
Amanda Defazio
Owner Owner's Name
information is Marstons Mills Ma 02648 3-4-2021
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
■N A. Inspector Information: Complete all fields in this section.
❑■ B. Certification: Signed&Dated and 1, 2, 3, or 4 checked
0■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
❑ D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
COMMONWEALTH OF R-Aq-SACHUSE TTS
EXECUTIVE OFFICE OF E�,v
1 J 1`I iRo-,,1IE! -rALA�
I DEPARTMENT OF E-NTVIROIv1vIEI`,m , p
RO_ECTION
TITLE 5
�/v l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSA,IENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ,
roperty Ad ress:
DAe.3-r R
Oners-'Am"e: E' /'�q e G e I
Owner's Address: /6� o r„ �o� �� h� ®
Date of Inspection: Jot
iv
Name of Inspector Iease print) i� M
i
Company Name:
Mailing Address: a
D164
Telephone Number:(— o _ Z;441
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal_system at this address and that the information reporter
below is true, accurate and complete as of the time of the inspection.The inspection was perfor_ned 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�Sec15 340 of Title 5(310 C1TR I:•ppp) the s�-ste
l/
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authori—t
Fails
Inspector's Signature: _ G Date:
� 0.6
The system inspector shall submit a copy of this inspection report to the Approving Autho��-(Board of H,:alth o
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design ro;,.Q=l(�,Opi?gpd or greater,the inspector and the system owner shall submit the report to the appropriate re�io�at oiT=ce of-�he
DEP.The original should be sent to the system owner and copies sent to the buyer,i,`anplicable_ and =e aprro�.
authority.
�pLm
vdi sp �ay.
`\otes and Comments /`"� �2 4 c 4
o�
""""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 perfor
conditions of use. m in the future under the same or different
Title 5 Inspection Form 611512000
Dade i
r
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNT-ARY ASSESS-NIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
P_9 RT A
CERTIFICATION(continued)
Property Address:
OiNmer• G 1 o -0
Date of Inspection:
Inspection Summary: Check A,B;C.D or E/ALWAYS complete ail of Section I?
A. System Passes:
i have not found any information which indicates that any of the failure criteria described in 33 10 C�-v '
15.303 or in 310 C_-NR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionallv Passes:
At�one or more system components as described in the"Conditional Pass section need to be replaced
repaired.The system,
p ed or
5 m upon completion of the replacement or repair,as approved by the Board of Health,will pass.
answer yes,no or not determined(Y;1-,1v7D)in the for the following statements. If"not deterim' ed"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 metaf septic tank will pass inspection if it is structurally sound;not leaking and if a Certificate of Co�liance
indicating that the tank is less than 20 years old is available.
N7D
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 it(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
N'D explain:
The system required pumping more than 4 unes a year due to broken or obstructed pipe(s). The s,rstem .7;
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
N7D exp'ain:
l
Page 3 of i I
OFFICIAL INSPECTION FORM-NOT FOR VOLL-.NTARY ASSESSIZENTS
SL-"BSL-RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtiI
P_A.RT A
CERTIFICATION(continued)
Property Address: /6 7 p!i►CO`�
//_ O Zvi
Owner: SGYt 0 oa b sj
Date of Inspection: /a
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 s
is failing to protect public health,safety or the environment. .sy_.em
i. System will pass unless Board of Health determines in accordance with 310 CIIR 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 fee:burl 50 fee or or 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 pprn,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form
3. Other:
T;rl� C T„c.orr;nn Z...-.,, 4!t
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR V"OLUI TT may-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-UNTSPECTIO1 FOR-I
PART A
CERTIFICATION(continued)
Property Address: /(� 60 CociG/ G-
Owner: 11 O OoZ6 j
Date of Inspection: / z
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the foliowi g for all inspections:
Yes \"o
(/_ $aekup of sewage into facility or system component due to overloaded or clooaed SAS ar c essnool
PIDischarge or ponding of effluent to the surface of the mound or surface.eaters due to anoverloaded or
ogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or ciouced S_zS or
sspool
Lei uid depth in cesspool is less than b"below invert or available volume is less than. V day f_ov
s/Kequired pumping more than 4 times in the last year NOT due to clog e
times pumped d or obsl cted pipz(sl.\`umbe-
Any portion.of the SAS, cesspool or privy is below high ground water zievation_
y pertion of cesspool_or privy is within 100 feet of a surface water supply or ti-ibuta to a surface
ater supply.
y portion of a cesspool or privy is v,i hin a Zone i of a public well.
day portion of a cesspool or pricy is within 50 feet of a private water supply w;z1 Any portion of a cesspool or privy is less than 100 feet but heater than 50 feet from a water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis.
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from poIlution from that facility=and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No) The system fails.I have determined that one or more of the above failure
described in 310 C va 15.303,therefore the system fails.The system owner shocriteria
d2 0 ct the Board of
Health to determine what will be necessary to correct the failure.
E. barge Systems:
To be considered a large system the system must serve a facility with a design flow of 1.U00 gpd to 15.000
gPd.
You must indicate either"yes"or no to each of the foLowing;
ke
criteria apply to large systems in addition to the criteria above)
ystem is within 400 feet of a surface drinkins water supply
stem is within 200 feet of a tributary to a surface drinking water su iy
terstem is located in a nitrogen sensitive area(Interim Wellhead Protection area—?�:,.���II of a public water supply well -
if you have answered"yes"to any question in Section E the system is considered a sign scant threat- - a_
"yes"in Section D above the large system has failed.The owner or operator considered
Iar�
Significant threat under Section E or failed under Section D sail , �e�+ o< �2i ed
e system considered a
15.304. The system owner should contact the a u gade •
p the system fn accord e-, ;;; ;0 �,
pprop :ate reaienal office ofhe D. " 2
epartmert.
Tiflo � Irenort;nn �'
Page ; of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUTTTARY ASSESSAIE�vTS
SUBSURFACE SEWAGE DISPOS<4L SYSTEM IISPECTION FOR,,
PART D
/r /(,_." CHECKLIST
Property Address: 16 7 oocor'c/ Z—G `�-
Owner:�� O
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the follow-g:
Ye�°
Pumping information was provided by the owner,occupant or Board of Health
11 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 m_cpec-Cion
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 sins of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site? .
fWere 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 infb anon 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 o
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 approximiation of distance
is unacceptable) ['10 CM R 15302(3)(b)]
I
Paae 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLL7_NT-4RY ASSESS BENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEMSPCZoaRr
PART C
/ SYSTEM INFORMATION
Property Address: 16 COI �v✓�
Owner: G� e � �f o02.6 S-15
Date of Inspection: 8 0 6
FL W CO\�ITIONS
RESIDENTL�I,
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x_of bedrooms): �30
Number of current residents: C;)--
Does residence have a garbage grinder(yes or no):�0
Is laundry on a separate sewage system(yes or no)�/ f ves separate r. ,
�LF p inspection requ edj
Laundry system inspected(ves or no):_/i�-V
Seasonal use: (yes or no):/"
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):Ike
Last date of occupancy:
C0;1tN1ERCIAL/LN'DUS TRIAL
Type of establishment:
Design flow(based on 310 C-�2 15.203): gpd
Basis of design flow(seats/persons/sgftetc.):
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 I-NTORMATION
Pumping Records ,�/ 1
Source of information: /v e
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How Nvas quantity pumped determined?
Reason for pumping:
TYPE SYSTEM
eptrc tank, distribution box,soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no) (if yes,attach previous inspection records,_f any)
_Innovative/Alternative technology.Attach a co f g3 p,'o he current operation and maintenance con_acr(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of 11
OFFICIAL, INSPECTIO-INT FORM—\OT FOR VOLUNTARY ASSESS �EN TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM I1SPECTION FOR_�-
PART C
SYSTEM INTFORMATION(continued)
Property Address: //
P _ L� O h CorL✓
Ovmer• ��C 0
Date of Inspection: Id- p
BUILDING SEWER(locat pn site plan)
Depth below grade: O
Materials of construction:_fit iron __other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints;venting,evidence of leakage,etc.):
SEPTIC TAI K:_ oc�eo. te plan)
Depth below grade:�
Material of construction:_ n�cS crete_Petal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(a�tacl a copy of
certificate) !
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: a
Scum thickness: z
Distance from top of scum to top of outlet tee or baffle:
i
Distance from bottom of scum to botto of outlet tee or baffle:
How were dimensions determined:
Comments.(on pumping recommendations.inlet and outle tee or baffle condition_ s1ruct-oral iniegrir . liouid levels
as re ted to outlet invert. evidence of leakage,etc.):
4 cs�
GREASE TRAP: locate on site plan)
Depth below grade:_
Material of consti-sction:_concrete—metal fiber glass 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 conditiom. suuctural inter L:, d et Ll;
as related to outlet invert, evidence of leakage,etc.):
Page 8 of 11
• OFFICIAL, INSPECTION FORM—NOT FOR VOI.UN ARY a,SSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-IT
PART C
SYSTEM INFORMATION(continued)
Property Address: v� (p,�C! G P_
Owner: 40
Oo2 6 f%
Date of Inspection: p2 b
TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(iocate on sit,n7_an)
Depth below grade:
Material of construction: concrete metal_fiberglass_polyethylene other(exnlaim):
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:V if resent P ,( p must be open.,d)(la.,ate on site plan)
Depth of liquid level above outlet invert:_el"V ! 4
Comments (note if box is level and distribution to outlets equal,any evidence of solids ca=over, art-e.,ide-ce of
leakage in or out of box, etc): '
o x Lev?
PUMP CHAwIBLR: (locate on site plan)
Pumps in working order(yes or no):
Alanms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.l:
-
Q
I
1
Page 9ofil
OFFICIAL IlNTSPECTIO:!FORM—NOT FOR VOLI,-N-TRY ASSESSN ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM n-,' --SPFC'TZON FOR AT
PART C
/ SYSTEM INFORMATION(continued)
Property Address: CQ[n zO/t�/
Owner: �G
Date of Inspection: d 0
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan.excavation not required)
If SAS not located explain why:
Type l / /2 — ��r T .
leaching?pits,number:_ 6 x
leaching chambers; number:
leaching galleries;number: th: j e"
leaching trenches,number,leng
leaching fields, number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil; signs of hydraulic failure,level ofponding, damp soil, condition of vecetatior
etc.): �v+ ��✓!, �.�.
O
CESSPOOLS:—k--(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 in-flow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level ofponding, condition of vegetaton_ etc.;:
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,Ievel ofponding,condition of vegetat3o--, e,c.,.:
I
Ti+lo G T*+c_,jF;n, r_n �/1 G77 nun n
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOI,L-�-T-A-Ry ASSESSAJENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-N-1
PART C
SYSTEM INFORMATION(continued)
Property Address:4"e,10�6�
e,p&/� 4 �,-y _
�i o
Owner:Date of Inspection:
SKETCH 4 SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference land-nary s or
benchmarks. L Dcate all wells within 100 feet. Locate where public water supply enters the wilding.
IA
i
i 3
/7/ - a�
�r
J
T;+lo G T»c»cr+in» �nrni 4/1 ci�nnn
n
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR tiOLLT�N�T_ARY ASSESSME''TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOPM
PART C
SYSTEM INFORMATION(continued)
Property Address: /(// �—
S
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water � 9
Check cellar
Shallow wells
Estimated depth to ground water oZ feet Co w
w
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan.reviewed:
Observed site(abutting property/observation hole-within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USES database-explain:
You must de scn e ho« you established the high around water ele-va
tion:
oZ lr 9
r 8r R i /7� • .s !f,5z) (�f-
I.r
T41— Tncnor
1
TROY WILLIAMS L_
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 3b5-1300
19 Hummel Drive
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSE'I"I'S
EXECLJTIVF, OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
"TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
ProperIN Address: 164 Concord Lane
Osterville, MA
Orsner's Name: Roger Anderson RECEIVE®
Owner's Addres,: 164 Concord Lane i
Osterville,MA 02655
Date of Inspection: November 29,2001 [SEC 112.
Name of Inspector: 1
P Troy M. Williams 068A6 E
Company Name: Troy Williams Septic Inspections i HEAPT.
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
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. 1 am a DEP
appro%ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system
v/ Passes
Conditionalb.- ('asses
Needs Further Fvaluauon by the Local Approving Authont)
Fails
Inspector's Signature: '�S ,r„r, Z,J,c Q��; Date: 12-/ y /a t
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification Is not to be construed as a guarantee of future working condition
of system;piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
**"This report only describes conditions at the time of inspection and under the conditions of use at that
time. 1 his 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 pace I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
164 Concord Lane
Owner: Osterville,MA
Date of Inspection: Roger Anderson
November 29,2001
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 a replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the B d of Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the for the following statem is. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank hether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure ' imminent. Svstem will pass inspection if the
existing tank is replaced with a complying septic tank as approved y the Board of Health.
*A metal septic tank will pass inspection if it is structurally so ,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 t or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled r uneven distribution box. System will pass inspection if(with
approval of Board of Health):
b en pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection ' with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:.
2
Page 3ofII
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
164 Concord Lane
Owner: Osterville,MA
Date of Inspection: Roger Anderson
November 29,2001
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 15.3 (1)(b)that the
system is not functioning in a manner which will protect public health,safety and t 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 s t marsh
2. System will fail unless the Board of Health (and Public W er Supplier,if any)determines that the
system is functioning in a manner that protects the public alth,safety and environment:
_ The system has a septic tank and soil absorptio ystem(SAS)and the SAS is within 100 feet of a
surface water'supply or tributary to a surface war supply.
The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic to , and SAS and the SAS is less than 100 feet but 50 feet or more froth a
private water supply well" ethod used to determine distance
"This system passes ' the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volati organic compounds indicates that the well is free from pollution from that facility and
the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criter' are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 164 Concord Lane
Osterville,MA
Owner: Roger Anderson
Date of Inspection: November 29,2001
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
NiA Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z da flow
Y
Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s .Number
gg PP ( )
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
4z-q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Nfii 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.
ti/9 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
/Jt) (Yes/No)The system fails. 1 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 d ign 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 crite i above)
yes no
the system is within 400 feet of a surface drinkin ater supply
the system is within 200 feet of a tributary a surface drinking water supply
the system is located in a nitrogen se hive area(lnterim Wellhead Protection Area—I WPA)or a mapped
Zone 11 of a public water supply l
1f you have answered"yes"to any q tion in Section E the system is considered a.significant threat,or answered
"yes"in Section D above the larg ystem has failed. The owner or operator of any large system considered a
significant threat under Section or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner s uld contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
164 Concord Lane
Owner: Osterville,MA
Date of Inspection: Roger Anderson
November 29,2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_ P..;,.-,ping information was provided by the owner. occupant, or Board of I Icalth
_ ✓ 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?
V1 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 l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
164 Concord Lane
Owner: Osterville,MA
Date of inspection: Roger Anderson
November 29,4tbW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): T Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: n -2
Does residence have a garbage grinder(yes or no): Ato
Is laundn on a separate sewage system (yes or no): ;yu_ [if yes separate inspection required]
Laundry system inspected(yes or no):_&Lj
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Uo- 80,jL o
Sump pump(yes or no): No
Last date of occupancy: Vu«-,'+
COMMERCIALANDUSTRIAL
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_ s or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: ��., <-- 8 /2 f /oo
Was system pumped as part otthe inspection(yes or 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):.
Approximate age of all components. date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):No
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
164 Concord Lane
Owner: Osterville,MA
Date of Inspection: Roger Anderson
November 29,2001
BUILDING SEWER(locate on site plan)
Depth belo" grade: /9" +
Materials of construction:_cast iron _,/ 40 PVC_Zother(explain): ;<, 4
Distance fron-. private water supply well or suction line: tie/j
Comments(on condition of joints, venting,evidence of leakage,etc.):
S�_��_�' ^c 5 tr.1. .t Y i✓...� C. �.c�.r r..r- �� ^Fi.n.,.0 a.l .0 � h S
SEPTIC TANK: v1 (locate on site plan)
Depth below grade:
Material of construction:_A[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: 5 2r'? X
Sludge depth: y'- _
Distance from top of sludge to bottom of outlet tee or baffle: 02 q „
Scum thickness: Ayaiv,6
Distance from top of scum to top of outlet tee or baffle: C
Distance from bottom of scum to bottom of outlet tee or baffle: iy
How were dimensions determined: P,,4 L _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
PUC, Tt� li✓ 1ti yF __ ••t
- I L. / - fi..-..A C...+ �1 a-✓'�•/' �-. '�4� T�.i �✓�t.4_t_w��.�K_^✓_!�✓1 _ _ a r� c..�:
k-
GREASE TRAP:_(locate on/site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_p ethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of o/etc.):
:
Distance from bottom of scum to bottr baffle:
Date of last pumping:
Comments(on pumping recommendatlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of
7
i
Page 8 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
164 Concord Lane
Owner: Osterville,MA
Date of Inspection: Roger Anderson
November 29,2001
TIGHT or HOLDING TANK: (tank must be pumped at time of in ection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal frberglas _polyethylene other(explain):
Dimensions:
Capacity: g/ordeyes
Design Flo%N. g
Alarm present(yes or no):
Alarm level: Alarm in woDate of last pumping:
Comments(condition of alarm and
DISTRIBUTION BOX:_V/ (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 intoor out of box,/etc.):
'J/'— 1 S w u 1 rL✓.�..0 I t •-r C.L. X �, 1..+./o r tti t r�<.i !.� i c} o u A
L _ ► c , I _._ _ T
�__
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,conditi of pumps and appurtenances,etc.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION(continued)
Property Address:
164 Concord Lane
Owner: Osterville,MA
Date of Inspection: Roger Anderson
November 29,2001
SOIL ABSORPTION SYSTEM(SAS):�/ (locate on site plan,excavation not required)
If SAS not located explain wh):
Type --— —
v1 leaching pits, number: 1 - k6 ' Z�.��L p," „,•�( �' ,,,� .
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, dam soil,condition of vegetation,
etc.):
P g ,
Ltt�l t /�. A a
ti !ht
IJr✓ 4 lgevbt•r..I .h ,', !A) t u/c.rt Yy✓r..� mm4.k -L fi ._- ./C .t-f fo.<, 4�. Oar
NA k G.
CESSPOOLS: (cesspool must be pumped as part of inspection)(1 Cate on site plan) C,�
SyS4-
Number and configuration:
Depth-top of liquid to inlet invert: _
Depth of solids layer:
Depth of scum laver. _
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of draulic 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 hydrauliZre, l of ponding,condition of vegetation,etc.):
9
i
f
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 164 Concord Lane
Osterville,MA
Owner: Roger Anderson
Date of Inspection: November 29,2001
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.
6 h.
1 '
1000
A C 7
03z' 13 12
141
6L, w r
10
r
Page 1 1 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:.
164 Concord Lane
Owner: Osterville,MA
Date of Inspection: Roger Anderson
November 29,2001
SITE EXAM
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water.26+ 'feet Adjusted high ground water elevation _ 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: ,? 27/8/
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: SDI <s 3 S Z , j L g. '
You must describe how you established the high ground water elevation:
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1 CERTIFY THAT THE 40U,7� SHo1h�N � -
NE R¢oN COMFQ?!5 V41TN-THE ISo6 1 LIN E or
A►,iD SE-c5AGK 2.6.Qu►R.EMEN'fs I+- 't1�E f�
To W N OF: 81�1Z►JST�'131:3 •-ANv 1 S 'NOT
LOGp.TED •WITH1 ,T .E G a PL.A11J
DATES � gp.xTE1Ze N`(E INC.
R.EGISZE.Q6'D 1.AwDSumYEY6>
-TIA15 PL&KI 11,5 WCOT BA56t'S G►d AM 05 rC-9-VILLE• - MA55.
IN5-1-RuMENT Su2v�Y 4�TNE 0FF5ET5 Suout� c
NoT DE V5E•D"Yd VETS-W�1►JE VaT 1►II.tE.�� APPL.IGANT �OLLCW5- LAEL
z6x
LO CATION SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME D ADDRESS
_ . t�CV
BUILDER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
1-6 r I �c
� F
No... � .......................
THE COMMONWEALTH OF MASSACHUSETT5
�w
BOAR® OF HEALTH
. ..5 .--:fir..---..-..of.-..... ::..t .�'�,.- , ..:... .......................................
Appliration for Uhipma1 Works Corm rur#inn Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at
... ��J�T ............................................. .................................... °�-' `�------------------------------------... _
Loc tion-Fyckdress ,r, - � or Lo N
m� �* y y,y
Owner� I(`� !/ *AY? V/a Address
a r� cy-•-------------•.......•--......----•-..... .....---t... -•••--••--•------•••••---•----_-.................................................................
Installer Address
Type of Building Size Lot....12?S.'._Sq. feet
,.., Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder CNJU)
'_l Other—Type T e of Building ..._...... No. of persons...............
Pa yP g P Showers ( ) — Cafeteria ( )
a' Other fixtures --------------------------------------------------
-------------------------------------------------
W Design Flow•..............S5 _-._..r----....:.gallons _ ._per person per day. Total daily flow.._.........I... . . ..............gallons.
W Septic Tank—Liquid capacity ---------...gallons
Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. ................... Width....Y-----.-.-.----
o Total Length............o._.---- Total leaching area....................sq. ft.
Seepage Pit No.----___1_._-_...... Diameter....-.-------- Depth below inlet.....'.......... Total leaching area...Zl ..sq. ft.
Z Other Distribution box (✓) Dosing tank /
I
a Percolation Test Result Performed by.-Wo. - r-LY- ------..A.Jn&*._f9Date
_......dzr- -------
Test Pit No. 1___i......minutes 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 Soil.................... . .............................................. .... -----------------------------------------=---------------------------------------
U .................................................... --------------------- ---------------.....----------------------------........---------------
W -----------------------------•---•----••-•--•........----•-•-------•--•-----------•----...-•-•-----•----•-------••--------------............--•--••---•••-•--•-•-...----------------------•--•••••-•----
VNature of Repairs or Alterations—Answer when applicable.......................................................... .._.._._....___....._........_.
Agreement:
The undersigned agrees to install the aforedescrib d Individual Sewage Disposal System in accordance with
i the provisions of'I I LL 5 of the State Sanitary Code The undersigned further agree not to place the system in
operation until a Certificate of Compliance has been i ed he a h.
d0 2—
Signed...
Application Approved By............................. � .,./Q'..��. ............................... .... ��1.--------------
Date
Application Disapproved for the following reasons--------------------- ---------------------------------------------------------------------------------------•--
--.........•--•-•---•--•---•••-••--••-------•••--••-----••-•-----------••-•••-••••----•••-•-•-•........--•---------••--•----•-•----•-•--•--•----••••------•---------•--------•-•-----•--••--••.......---
Date
PermitNo......................................................... Issued.......................................................
„r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. .....................O F....................._..........----...------------------....••-•
Appliratiun for DiopuoFal Works Tonotrurtion Fermi#
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
.................................•--•---...-•--•-....--•---.............---------•-•••-•••......-• ..................................... ..........................................................
Location-Address or Lot No.
..........• ---..•.........................•.......... ............................................ --•--•------............•.............._..
� C.6 / Owner Address
Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ---------------------------••-•• .
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.____-___--_-._._... Depth to ground water........................
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-------•------------------------•--••------•-••--.._....------------•--..............--•---•---•---.........................................................
0 Description of Soil.......................................................................................................................................................................
W
w
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 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.
Signed..............................................................------•--••-••--•-•••-- ................................
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•-•--••--•••.....
..................•-._....................---...----•-••----•----------•------._.....--------•-....-----------••--•••--•-•-••---•-------•---•------......-------••--•--- ...............................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
4,1&_ (9prfifirFatr of Tontph ana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-•••.................•---- . -/Cl� .Jd 2-...........................................................................................................................................
Installer
at ` r/�---------�= _ j . -........................-.....................................................
has been installed in accordance with the provisions of TI”' r j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__..... ."`K;V______________ dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................. � _. Inspector................ .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF HEALTH
...........................................OF -•-••-....................... ... +
No........ ....y ... FEE........................
Disposal or1K15 Tyono#r ion rrmit
Permissioni!,bgreby granted........ 1/ -! ` `.......-•------------------•-------------•-------..._....--------.....------.......---•--............-•.•.--•
to Constru t or epair ) an Individu 1 Sewage Disposal System
atNo........ _ C....3- r.... ....... .1- -----•-------------------------------------------------•----------•--•--....---•-•-�
Street
as shown on the application for Disposal Works Construction Permit
• No..................... Dated..........................................
.........
d--f-------------------•-------•-----------•--
DATE-------•-------- ........................................ - r no Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
S� 5� o Leh •�R r��. :��e'*•�� - -
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