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Home My WebLink About0084 HARTFORD AVENUE - Health 84 HARTFORD AVE.n u Li- A= 103 044 Q S. 7wt a , y i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 s 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. General Information on the computer, use only the tab 1. Inspector: V� key to move your cursor-do not Darrell Stone use the return key. Name of Inspector Cape Cod Septic Inspection Q Company Name P.O. Box 1466 Company Address Harwich City/Town MA 02645 State Zip Code 508-240-2500 S14995 � Telephone Number License Number 4, B. Ce ification [y,l ri) certify that I have personally inspected the sewage disposal system at this address and that the cis 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 c. sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of U- jitle 5(310 C R 15.000).The system: C) o ® r" Co ditionally Passes � N El Fails ❑ ed rther luati a Loc Approving Authori pector's Signature Date 4 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Sutuurfa Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 4'V s•�'`t 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.), Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have...not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*orIthe septic tank whether metal or unsound ( . not) is structural) exhibits substantial infiltrate y on or exfiltration or tank failure is imminent. System will pass inspection.if-the existing tank is replaced with•a complying septic tank as approved Health. p pp oved by the Board of *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a.Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below):' t5ins•3/13 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner s Name information is required for every Marston Mills, MA 02648 3-17-14 page. City/Town ' - t Stae Zip Code p • ate of inspection- B. Certification (cont.) i ❑ Pump Chamber pumps/alarms not operational. System will pass with,Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced° ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ElND (Explain below): ❑ distribution box is leveled or replaced - ❑ Y ❑ N ❑ ND(Explain below): i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): r 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water 1 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 4. 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 • 100 feet of a s rp (SAS)and the SAS is within surface water supply or tributary to a surface water ter supply. F ❑ 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 SA S is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ' ;• to D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No".to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool, ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M s 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name - IF information is required for every Marston Mills, MA 02648 3-17-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection -Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. City/Town , State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of,liquid;depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): '`' n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR•15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 4 Bedroom residential dwelling Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: } gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. El Other(describe): .. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1992 Per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 21" feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 15" feet Material of construction: ® concrete ❑metal ❑fiberglass 9 El polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: <21, t5ins•3/13 y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owners Name information is required for every Marston Mills, MA 02648 3-17-14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 61 Distance from bottom of scum to bottom of outlet tee or baffle A6" How were dimensions.determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grade to inlet cover 3" Outlet 5" Normal liquid level No sign of leakage SCH 40 tees Recommended next maintenance pumping within 3 years Recommended maintenance pumping every 2-3 years Grease Trap(locate on site plan): F Depth below grade: feet Material of construction: ❑concrete ❑ meta ❑fiberglass. l 9 El polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 ` _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 84 Hartford Ave Marston Mills, MA Property Address Steven Brito h Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet inver t, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: El Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date ' Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subs urface surface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. Cdyrrown State Zip Code Date of Inspection 4 D. System Information (cont.) Distribution Box(if'present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 :. Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito h Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® . leaching pits number: 1 i ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1 (6x6') pit with 2'stone Grade to pit 33" Cover 9" Bottom 117" Dry No sign of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer. Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments M 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. City/Town State Zip Code Date of inspection- D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy.(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note`condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins• /t 'Y 3 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address t Steven Brito ` Owner Owner's Name f information is required for every Marston Mills, MA 02648 3-17-14 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately eo,( -t I A r� I I e A Y 2 6 2 3 v- 3 4 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope } ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water- >4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: See below You must describe how you established the high ground water elevation: Elevations from USGS maps Approximate property ELV. 92.0-95.0 Approximate bottom of SAS ELV. 82.25-85.25 Approximate GW ELV. 45.0 -46.0 Adjustment 3.1' SDW-253 Zone B 48.90' February 2014 Separation >4' Before filing this Inspection Report, please see Report Co mpleteness letenes s Checklist on next page. t5ins•3/13 1 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Insp-ection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 84 Hartford Ave Marston Mills, MA Property Address Steven Brito Owner Owner's Name information is required for every Marston Mills, MA 02648 3-17-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE 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 Property Address: Owner's Name: 2v� Cl rd ,Sys✓t�- ,(�j✓ (fV Owner's Address: �� 3'J'd�J Date of Inspection: Name of Inspector: (please print) Joseph M. Martins (� Company Name: Rccu Sepcheck Mailing Address: 17 Northside Dr., S. Dennis,MA 02660 Telephone Number: 508-385-5891 r CERTIFICATION STATEMENT + T; I certify that I have personally inspected the sewage disposal system at this address and that the in:formation-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: Lle Passes Conditionally Passes # �' Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ®d L The system inspector shall sub Ztaopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11. t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 84 Hartford Ave,Marston Mills, MA Date of Inspection: Brito 5/17/2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Condition ass"section need to be replaced or repaired.The system, upon completion of the replacement or repair approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the the following statements. If"not determined"please explain. The septic tank is metal and over 20 yea old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or filtration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a compiyi septic tank as approved by the Board of Health. *A metal septic tank will pass inspec . n if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less th _0 years old is available. ND explain: Observation o ewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Boar of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND xplain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction.is removed ND explain: Page 3 of 11 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 84 Hartford Ave, Marston Mills, MA Owner: Brito Date of Inspection: 5/17/2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by th and of Health in order to determine if the system is failing to protect public health,safety or the environme . 1. System will pass unless Board of Healt etermines in accordance with 310 CNIR 15.303(1)(b)that the system is not functioning in a man which will protect public health,safety and the environment: Cesspool or privy is wi n 50 feet of a surface water _ Cesspool or privy i . ithin 50 feet of a bordering vegetated wetland or a salt 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 publi ealth,safety and environment: _ The system has a septic tank and soil abso on system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfac ater supply. _ The system has a septic tank an AS and the SAS is within a Zone I of a public water supply. _ The system has a septic k and SAS and the SAS is within 50 feet of a private water supply well. _ The system has eptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup well**. Method used to determine distance **This sy in passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacte ' and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 84 Hartford Ave, Marstons Mills, MA Owner: Brito Date of Inspection: 5/17/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No P-1-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 __Az- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow _ _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _✓Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _✓Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.[ (Yes/No)The system fails. t 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 w' a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the followi (The following criteria apply to large systems in addition the criteria above) yes no — _ the system is within 400 feet of a s ace drinking water supply — _ the system is within 200 fe f a tributary to a surface drinking water supply the system is locate ' a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone f I of a pu 'c water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 84 Hartford Ave, Marstons Mills, MA Date of Inspection: Brito 5/17/2006 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No -V— Pumping information was provided by the owner,occupant,or Board of Health __ Were any of the system components pumped out in the previous two weeks V __ Has the system received normal flows in the previous two week period — Have large volumes of water been introduced to the system recently or as part of this inspection V _ 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 at t l to�°:files or tees,material of construction,dimensions,depth of liquid,depth of sludge d depth of scum IWas the facility owner(and occupants if different from owner)provided with information on the proper Maintenance of subsurface sewage disposal systems p 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 Cis at issue approximation of distance is unacceptable) [310 CIMR 15.302(3)(b)] Page 6 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 84 Hartford Ave, Marstons Mills,MA Owner:Date of Inspection: Brito FLOW CONDITIONS 5/17/2006 RESIDENTIAL Number of bedrooms(design): !' Number of bedrooms(actual): / �� %j( vat DESIGN flow based on 310 CM ,1.5.203(for example: 110 gpd x#of bedrooms): Number of current residents: .5 v Does residence have a garbage grinder(yes or no).— Is laundry on a separate sewage system(yes or no):NO if yes separate inspection required] Laundry system inspected(yes or no): IVA+ Seasonal use: (yes or no): Na Water meter readings,if availe(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:—P--RQnf 14 vl -::7 a 53 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sgft,etc Grease trap present(yes or no): Industrial waste holding tat esent(yes or no): Non-sanitary waste d' arged to the Title 5 system(yes or no):— Water meter re gs,i f avai!able: Last date 'cupan,,-y/use:_ OTHER(describe): GENERAL INFORMATION Pumping Records , J�/�/J y jn ,�/�Sourecoi"information: � � 'oZOQ L � D�/IG� Was.system pumped as part of the inspection 6 .or no): If yes, volume pumped: -al Ions--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, i f any) _ innovr!tive/Altern ative 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): Aonroxlma'_ I le of ail components. dais;:_istalled(!f lanor�n)and source of nfor!zi t!:,n: vo .Were s;,vagc odors detected when arriving at the site(yes or no): /) Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 84 Hartford Ave, Marston Mills, MA Date of Inspection: Brito 5/17/2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: ✓cast iron _40 PVC other(explain): Distance from private water supply well or suction line: _>iQ/ Comments(on condition of joints,venting,evidence of leakage,etc.): SIEPTIC TANK:_(locate en site plan) Depth below grade: h S ��5�✓ �i(/ / i//) 6 rr Material of construction:_concrete_metal_fiberglass_polyethylene If tank is metal list a0e:_ Is age confirmed by a Certi.5ficate of Compliance(yes or no):—(attach a copy of Dimensions: certificate) 1/O /r )(F p/ 1f�/ /7// /0 Sludge depth:��--_�------_-- Distance from top o sludge to bottoin of outlet tee nr baffle:_�7 _ Scum thickness: — Distance from top of scum to top of outlet tee or baefle:�—_ Distance B oon botto�r, of,c�,n to l ottoen of outlet t e or I .ft?;: lot-If v� e v�Q� Flow were dimensions determined: _/ �-- Yit�� -� / . Comments(on pumping recommencati� inlet and outlet tee or � e co structi cal integrity, liquid levels as rr.-Iated to owlet invert.evidence of Lak• e, Lbon vX40 2 r GREASE TRAP:_(locate on site plan.) Depth b,�!o/grade: _ Material of construction:_concrete_metal_fiberglass yethylene_other (explain):_ Dimensions: Scum thickness: Distance from top of scum to outlet tee or battle: Distance From bottom um to bottom of outlet tee or baffle: Date of last pu g: Comment n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as ed to outlet invert,evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 84 Hartford Ave, Marston Mills,MA Date of Inspection: Brito 5/17/2006 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallo ' ay Alarm present(yes or no): _ Alarm level: Alarm ' orking order(yes or no): Date of last pumping: Comments(conditim of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of purr amber,condition of pumps and appurtenances,etc.): Page 9 of l l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection• 84 Hartford Ave, Marston Mills, MA Brito SOIL ABSORPTION SYSTEM(SAS): (locate on site pl&W tion not required) If SAS not located explain why: Type �eaching pits,number: �n W Q�l J Ae Pro leaching chambers, number:v_ ieaching galleries,number: _ leaching trenches,number,length: leaching fields,number,dimensions: _ overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, eta_): C/ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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' ow(yes or no): Comments(note condi ' n of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of- ; , signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 'r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 84 Hartford Ave, Marston Mills, MA Date of Inspection: Brito 5/17/2006 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. Vv 0 3 l 2 Q 1 C ' s` - a-2 —s7 . , 83- 07 Page OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date r:Inspection: 84 Hartford Ave, Marston Mills, MA Brito SITE EXAM 5/17/2006 Slope Surface water Check cellar Shallow wells Estimated depth to ground water9 — 3 7 ' Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _Accessed USGS database-explain: 44 S Cr S 7-662 0 C C C e I q?Z G'r'aVdw,oA' ('on�v✓S You must describe how you established the high ground water elevation: 3 . &MIxI wotkv, 6011Mly'- IS y /)?/�-x ks-e' O;zI Commonwealth of Massachusetts Executive Office of Environmental Affairs 9N Dept. of Environmental Protection ki One winter Street,Boston,Ma. 02108 John Grad D.E.P. Title V Septic hispector p P.O. Box 2119 Teatic WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI cO Lt.Governor IVE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � CERTIFICATION PART A NOV 3 19g, Property rt Address: 84 HARTFORD AV.MARSTONS MILLS oy Address o Owner: Date of Inspection: 10/23/98 (If different) Name of Inspector: JOHN GRACI RICHARD GROUT;63 OLD FIELDS RD.SAND tl r I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) E Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined In Title V _ Conditional) asses code 310 CMR 16.303.My findings are of how the system is y performing atthe time of the inspection.My inspection does _ Neeiubmit rt er Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevkyofthe FHI I septic system and any of Its components useful tire. i Inspector's Signature: Date: 1o131r98 The System Inspector shall a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 007197) -1049 • Telephone 617 292-5500 One Winter Street • Boston,Massachusetts 02108 FAX(617)556 p ( ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address. 84 HARTFORD AV.MARSTONS MILLS Owner: RICHARD GROUT;83 OLD FIELDS RD.SANDWICH Date of Inspection:10123199 _ Sewage backup or.breakout or hioh static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surfaco of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 84 HARTFORD AV.MARSTONS MILLS Owner: RICHARD GROUT;83 OLD FIELDS RD.SANDWICH Date of Inspection:10123198 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the.system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 84 HARTFORD AV.MARSTONS MILLS Owner: RICHARD GROUT;63 OLD FIELDS RD.SANDVACH Date of Inspection:10/23199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x _ The system does not receive non-sanitary or industrial waste flow. _X_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is unacceptable)(15.302(3)(b)] (revlaed 04127)97) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 84 HARTFORD".MARSTONS MILLS Owner: RICHARD GROUT;63 OLD FIELDS RD.SANDWICH Date of Inspection:10/23199 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g•p•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd). nfa Sump Pump(yes or no): No Last date of occupancy: nfa COMMERCIAL/INDUSTRIAL: Type of establishment: nfa Design flow:8 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nfa Last date of occupancy: nfa OTHER:(Describe) nfa Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED IN JAN 98 BY HICKEY System pumped as part of inspection: (yes or no)No If yes,volume pumped:8 gallons Reason for pumping: r9a TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: SYSTEM IS 29 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) No (revlaed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 84 HARTFORD".MARSTONS MILLS Owner: RICHARD GROUT;03 OLD FIELDS RD.SANDVVICH Date of Inspection:10123198 SEPTIC TANK: x (locate on site plan) Depth below grade: V Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6"H5'7"w4'10" Sludge depth:"' Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY Two YEARS. GREASE TRAP:_ (locate on site plan) Depth below grade: Na Material of construction: _concrete_metal_FRP_Polyethylene_other(explain} Dimensions: Na Scum thickness:Na Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or baffle: Ne Date of last pumpingnl, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Na BUILDING SEWER: (Locate on srte plan) Depth below grade: 1'6^ Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction IinerowN Diameter: Na 1nv,lmments: (conditions of joints,venting,evidence of leakage, etc.) (reylaed0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 84 HARTFORD AV.MARSTONS MILLS Owner: RICHARD GROUT;63 OLD FIELDS RD.SANDWICH Date of Inspection:10123199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: we Capacity: rda gallons Design flow: rda gallons/day Alarm level-#a Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n1a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nia Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_va: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n!a (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 84 HARTFORD AV.N4IARSTONS MILLS Owner: RICHARD GROUT;63 OLD FIELDS RD.SANDWICH Date of Inspection:10/23/99 SOIL ABSORPTION SYSTEM (SAS),x (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits, number: 1000 GALLON LEACH PIT leaching chambers, number:nla leaching galleries,number: rda leaching trenches, number,length: rda leaching fields,number,dimensions:r9a overflow cesspool, number:Na Alternate system: nla Name of Technology:_rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.Prr HAS NOT HAD MORE THAN T OF WATER IN IT. r CESSPOOLS:_ (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: nla Depth of solids layer: rda Depth of scum layer: rda Dimensions of cesspool: rda Materials of construction: rda Indication of groundwater: rOa inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: rda Dimensions: Na Depth of solids: nra Comments: (note condition of soil,sigrs of hydraulic failure,level of ponding,condition of vegetation, etc.) n!a (revlaed 04r2T)9T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 84 HARTFORD AV.MARSTONS MILLS RICHARD GROUT;83 OLD FIELDS RD.SANDWICH 10/23198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) o U AA �r3L A 6 � (revised04)27197) page f of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 94 HARTFORD AV.MARSTONS MILLS RICHARD GROUT;63 OLD FIELDS RD.SANDIMCH 10123199 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revloed=27197) rage 10 of 10 L �TOWN OF BARNSTABLE Lr'1,11ON SEWAGE # VILLAGE ASSESSOR'S MAP & LO . INSTALLER'S NAME&PHONE NO. ry� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �` (size) MQ 0- NO.OF BEDROOMS BUILDER OR OWNER kUN3 Ll4 eLA= PERMPTDATE: COMPLIANCE DATE:.. �� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t x ww. ..«+.. .. ..s.-...n.a... ., ..rw�-.,«,y�+� 7. :.�'a y$it_. �d��.,,r„_,,,",.<........w ,-_w ... ,•.- . v.s .•� �� A,`.�'{.�.f. ice•: . TOWN OF BARNSTABLE LOCATIONff// 7 �1gI�� SEWAGE # II,LAGE Al VS IM Ail OD ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /^ SEPTIC TANK CAPACITY LEACHING FACELrrY: (type) L—tot?a Q/ T (size) f0 Y1 Ltl 2'5*Ae— NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /�" Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching acility) k"ea& A' Feet Furnished by ,',r(� A 4-1 �LCt1 `.Oak! 33 62-Zo' , Z TOWN OF BARNSTABLEr�L/ " LOCATION EWAGE # - VILLAGE M _ `M,�\ � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. tiltL:�tt Ctj4S7- SEPTIC TANK CAPACITY 11,000 LEACHING FACILITY:(type) it (size) \100C NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER BUILDER OWNER II. DATE PERMIT ISSUED: 2� Z DATE COMPLIANCE ISSUED: / VARIANCE GRANTED: Yes No �/ a.3 �Gu - r O rj f S� 0_.............../ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH eern �APPROVED acXm=,-j TOWN OF BARNSTABLE _ A Iiratiou for Disposal ors Tons�� k tr�rttn uttt en Application is hereby made for a Permit to Const;uct ( ) or Repair (X) an Individual Sewage Disposal System at: V'M)A ..... ....__... �ti�_ ,�;t�R- . YP,�I L-----------------------f- ------•---•---.......---................... ----•----......--•------................-- .... Location-Address o 19 .....Cz..��..........�......-�-U�-•�•--------•----•............................. ..........�4 2 '�.J ,`.. �rc(.. Owner Address Hi�l�l.�C.. m►�SZ_ �� 8...............................�' fE'lAi!1k4A. Installer Address PQ Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms.............................. .....Ex Expansion Attic— --------- p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------------------••----•--•--••--••------•-----------•-•-•-••-•••--••--•-•-................................--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic 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 ( ) `" Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------_................. fit Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ a' •---•-•-•---•---------------••-•••••-•-•-•-••---•-•••-••••-••--•-•-••-•......-•---•••-----•--•---•...---•-----•-•••-••----•-•-•---••-------•-----•---..-•---- O Description of Soil--P- 2............ U-2------------------•---_�••................N 4-. S-AONa x w Z -•-•-----------------------------•--•------•--•---•----------••-----------------------....••••••---•-----------•--------------------•-•--------•-•-•--------•••--•-•-•••-•----..._..............-------- U Nature of Repairs or Alterations—Answer when applicable._..L!�t J_K"=u..__..._N V4ci__.___._._..?�b�?�?._:_.__�LLO iz .. (J --- = ----------- .... f long CA: c a�c3 `- r�e _. $%� `'' '2 7 S TZ)d c_ . .. ...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp 'ante has been issued by the board of health. Signed .... Jz..--.... _l.��- { :. ... Dace Application Approved By ............... . ....................................................................... Dare Application Disapproved for the following reasons: ...... ........................................................................... .. .. ....................................... - - — - --------------- - -- ------------- ................................. Date Permit No. ............. --...J...-e----------------------- Issued Date No.---t.:.a- FRB... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE /�-,Q��.� �� / / Applira#iun for Uispusal Works Toustrnr#iun trod# Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal System at: tIA�2. T .....-----.--•Wv ....-•-------•----...... ...................................................... Location-Address or No. ......................-� �1 as u r _m� r�s►�,�s Mt -s............................................ Owner Address ..... �ekcc.c C'o S ---•-.�o_.. QN�-------------- 3........!?a !'`�..........................� N .S..........----........ ---------•----------•----- ------ --- Installer Address PQ d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder. ( ) aW Other—T e of Building _._.. No. of persons............................ Showers YP g -------------•----•-•-- P ( ) — Cafeteria.(....). dOther fixtures -----•-------------------------•---•-•---------•------............•------••••••. •-••-•--••---•••-•-••••-......-•_.. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic 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........................ (L, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--••---••-•--•--•--•---•----•-••••••-••-•-••••••--••-•-•--••••••••-••-••--••••----•.........•-•---•......................................................... O Description of Soil..d` .........-Ste................. .Ca. -----�°�. _r4k)----•--- 17t. Saar . ...... x W 7 UNature of Repairs or Alterations—Answer when applicable-___ -------- 4 The .......K--------------- - ?�..-----•.. �.tOvc>..... �s1 = '2 /Agreement:undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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 ..-- ......... :: ..... ----------------- ........... �z.g Dare ApplicationApproved By ............. - ---------------------------------------------------..----------------:- .........1-- )_.9.-- _?1..? Date Application Disapproved for the following reasons- ----------- - -------- --------------------------------------------------------- ----------------------------------------------- - --------------------------------------- --------------- ------------------- g 1 Dare PermitNo- ------------- ....... .e....................... Ilssued ........................................... ------.........------ Date THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH TOWN OF BARNSTABLE Trdifirate of To ntyli? nre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (>O) by.... .......... c "----�D-----L"'`------------------------------------------------------------------------------------------------------------.......................................... Installer at 'y (-1 �"C F'o�,�......_---. U.L......... .... (1`.h'c&Tbil-i. M•�� --------------------------------------------------- - --------- ---------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......�/..V.... a.-�------.--- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. ..................................................... Inspector .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �t TOWN OF BARNSTABLE �d No.....1... ......02;R FEE........................ Disposal Works %Tuuutrurtiun ami# Permission is hereby granted....''ev_e � <'�?.:..I. �Vkj.c to Construct ( ) or Repair ) an Individual Sewage Disposal System at No...•••••�� \),,� R on Jp P"J t " t--s tb� L r'!:�`�- • . . •............... ..••---••-----•.........--•..----- -----------•-•--•---•-••-----•••-• . -•---------------------- ................. Street91) c�yy as shown on the application for Disposal Works Construction Permit No.J.d-�t1-... Dated.......................................... 1 --------•-•••-......•••••-••-••-•--•••--.....••... DATE.............I _ ....................... Board of Health -----•-----• -------------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS