HomeMy WebLinkAbout0058 HAZEL PATH - Health 58 HAZEL PATH, MARST.MILLS
A=063.029
Commonwealth of Massachusetts
WON
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 7-6-12
page. CitylTown 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.
ImportaRing out f When A. General Information r
Ring out forms
on the computer, r !
use only the tab 1. Inspector: `
key to move your
cursor-do not James D.Seafs
use the return key. Name of Inspector
Capewide Enterprises LLC
-IL 1! Company Name
153 Commercial Street
Company Address
Mashpee_ MA 02649
Cityrrown State Zip Code
505477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
�s
zr I v
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority f ;,,
7-6-12,fi
speciors signature Date
The system inspector shall submit a copy of this inspection report to the Approving AutF ority'(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.
tSins•11/10
Title 5 Official Ins onrr Subsurface Searape Disposal Syst •Pape 1 of 17
Jul06 12 10:08p p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,/ 58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 7-6-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11110 TU 5 t3rGdal Inspection Form;Subsurrace Sewage Disposal System•Page 2 or 17
Jul06 12 10:08p p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is Marstons Mills MA 02648 7-6-12
required for every _
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes (cunt):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N D.ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system Is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ms•111110 rille 5 Official Inspection Form:Subsufam Sewage Disposal System•Page 3 of 17
Jul06 12 10:09p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (�
58 Hazel Path 1
Property Address
Lisa Kent
Owner Owner's Name
information is required for every Marstons Mills MA 02648 7-6-12 f
page. CityrFawn State Zip Code Date of Inspection
B. Certification (cont.) i
I
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. I
❑ The system has a septic tank and SAS and the SAS is within a Zone t ofla public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well. 4
❑ 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 weir*.
Method used to determine distance:
r
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:
t
I
1
i
f
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
19 or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than %2 day flow
t5ins•i lit 0 Title 5 Ofhdel brsped9on Form:Subsurtaoe Sewage Disposal System•Page 4 of 17
Jul 06 12 10:09p p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owners Name
information is Marstons Mills MA 02648 7-6-12
required for every
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 40D feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El Area
system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well,
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins-11110 - Title 6 Olfidal h"dian Form:Subwdaca Sawago Disposal Systam•Page 5 of 17
Jul 06 12 10:09p p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is required for every Mar5tons Mills MA 02648 7-6-12
page. City/rown 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
ED ❑ 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)j
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
wins 11lSD rvie 5 Ofrrcial hispec ion Form Subsurface Sewage Disposal System.Page 6 of 17
Jul 06 12 10:1Op p.7
Commonwealth of Massachusetts
IWTitle 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
O 58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
requirefo is Marstons Mills MA 02648 7-6-12
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 gal precast tank d box and 4 infiltrators
Number of current residents;
0
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 0 No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2010,79,000Gal
2011,48,000Gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commerc➢allindustrial 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:
15ins-11/10 T(Is 5 Official Inspection Form:SUhW80e Sewage Disposal Syetem-Page 7 cf 17
Jul06 12 10:10p p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Volunt
ary Assessments
U11-
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is
required for every Marstons Mills MA
02648 7-6_12
page. Cltylrown 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: 2008
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determine
d?
.
Reason
e son 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 UA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
thins•11H 0 This,5 Official Inspection Forth:Suo—Rice Sewage Disposal sysiam.Page a of 17
Jul.06 12 10:10p p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner owner's Name
information is required for every Marstons Mills MA 02648 7-6-12
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Leaching 1999 permit # 99-221
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 2'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.):
Camera lines, clean and solid
Septic Tank(locate on site plan):
Depth below grade: 16"
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal Precast
Sludge depth:
2"
t5ins.11110 Title 5 Offidal inspection Fwm:Subsurface Sew
age ways Disposal System•Page 9 of 17
7
Jul 06 12 10:11 p p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is
required For every Marstons Mills MA 02648 7-6-12
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
Septic tank (cons)
Distance from top of sludge to bottom of outlet tee or baffle
28"
"
Scum thickness 1 _
Distance from top of scum to top of outlet tee or baffle 12"
Distance from bottom of scum to bottom of outlet tee or baffle
1710
How were dimensions determined? Tape, Asbuilt
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to oudet invert, evidence of leakage,etc.):
Tank at working level, inlet Tee, outlet Baffle, Tank at 16"w/both covers at grade Tank and
covers under deck, Note: Trap door in deck over both covers, no sign of leakage or over
loading
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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•11l10 M 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Jul 06 12 10:11 p p.11
Commonwealth of Massachusetts
61 Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 7.-6-12
page. Cityll-own State Zip Code Date of Inspection
D. System information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date -
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
[Sins-11no Title 5 0`Fdai Ins pedion Form:Subsurface Sewage Disposal Sy3esm-Page j t or'17
Jul 06 12 10:11 p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information Is
required for every Marstons Mills MA 02648 7-6-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16" 25" Below grade Box is clean and solid w/one line out No sign of over
loading or solid carry over
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 5 Official Inspedior.Form:Subsurface Sewage Disposal System•Page 12 of 17
Jul06 12 10:12p p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Hazel Path
Property address
Lisa Kent
Owner information is Owner's Name
required for every Marstons Mills MA 02648 7-6-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Type:
❑ leaching pits number.
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovativelalternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four infiltrators per permit w/4' stone. Leaching at 42"below grade„ T.H. above
and beside leaching sand and stone clean and dry, camera out to leaching, no sign of over
loading or solid carr over
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
tans•11110
Title 5 Official hspeclim Forth:Subsurface Sewage Disposal System•Page 13 of 17
II
Jul06 12 10:12p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -(dot for Voluntary
ry Assessments
56 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is every Marstons Mills
required for eve MA 02648 7-6-92
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
ISins-t1110 Title 5 Official Maperlion Fomc Subsurface Sewage Disposal System-P8"t4 of 17
Jul06 12 10:12p p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
" 58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 7_6_12
page. C tyrrown
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
l�
O
a
4�
cf
1�' f ' 1q
43 =
t5ins•11110 Title 5 otfidal brpedion Farm:Subsurface sewage oisposal system•Page 1s of 1?
Jul06 12 10:12p p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owners Name
information is
requl red for every Marstons Mills _ MA 02648 7-6-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water. 45'+
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:
USGS WELL SDW 253
You must describe how you established the high ground water elevation:
area high no sign of g.w. problem
usgs well sdw 253 at 48 64 adj 2' 3'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins 11l1D Tdla 5 Official Inswcpon Fcrvr Subsurface Sewage Disposal System•Pege 16 of 17
Jul 0612 10:13p p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owners Name
information is
required for every Marstons Mills MA 02W 7-6-12
page. City/Town State Zip Code Date of Inspection
E. Report Completeness
p p eness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•1Ui0 Title 5 Official Inspection Form:SubUrface Sege Disposal System•Page 17 or;7
Jul06 12 10:13p p.18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Kent
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 7-6-12
page; Ci flown 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 A. Genera! Information
filling out Corms Upptuutlupp���
on the computer, ����w�A"OF Af'4
use only the tab 1 Inspector: ��`y� "' 'q �.
.
key to move your '_- •Ly
cursor-do not 'moo JAMES N
James D.Sears =Z; m
use the return =o
key. Name of Inspector
Capewide Enterprises. LLC
I Company Name
153 Commercial Street slnu sP1EG\
Company Address -
n Mashpee MA 02649
City/Town State Zip Code
505-477-8877 S1623
7eiephone Number License Number
8. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. )am a DEP approved system inspector pursuant to Section 16.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7-6-12
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
E5hs-1111D Title 5Oflicial lnapection Form:Subsu,'ace I sewage Disposal system•Page 1 of 17
f_
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is Marstons Mills Ma. 02648
required for 9/18/2008
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector: �I I
only the tab key
to move your Robert Paolini /
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
Cityrrown State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
µ
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 meintenan"of on;site
sewage disposal systems. I am a DEP approved system inspector pursuant to lSection15.34'of J
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails cv
❑ Needs Further Evaluation by the Local Approving Authority a
ry
CU
Cn
9/18/2008 - � r
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2
r
Commonwealth of Massachusetts
9-3
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in porper working order at the present time.
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. t
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)-
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hazel Path
Property Address `
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
E] ® 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-
1 0,000g pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
.Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® _ Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® El available
as,built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out? .
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 58 Hazel' Path
Property Address
Lisa Sealey Kent,
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
System consists of 1-1000 gallon septic tank,D-Box and 4-Infiltrators.
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2006:42,000
g ( Y g (gp ))' 2007:63,000
Detail:
Sump pump? ❑ Yes ® No
9/18/2
Last date of occupancy: Date 008
D
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): . Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of'information: Capewide Enterprises,LLC.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured
Reason for pumping: Maimtenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a.copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe): `
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of.Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
New Leaching installed in 1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1 on
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20'+
feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
t
Septic Tank(locate on site plan):
18"
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
Dimensions:
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is Marstons Mills Ma. 02648 9/18/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
Scum thickness 0
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 NA
How were dimensions determined? Tank pumped at inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appear to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
r
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sealey Kent
Owner' Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
a
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): .
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is level.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑' Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12
I
�. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sea'iey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.
l
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to.inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is
required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
r
Map Page 1 of 2
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http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=063029&map... 9/23/2008
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 70'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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USEMUSGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 58 Hazel Path
Property Address
Lisa Sealey Kent
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 9/18/2008
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 117
TOWN OF B ARNSTABLE
LOCATION 7 SEWAGE # '✓�.` �
VILLAGE /r. In,1 l l c ASSESSOR'S MAP& LOT -. )
INSTALLER'S NAME&PHONE NO. /YI 1!J CX 1/1 e
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 7VA �Z4rafl.f (size) _ �,1�/�,�;2- )7 _
NO.OF BEDROOMS
BUILDER OR OWNER i J
PERMITDATE: % I
COMPLIANCE DATE: ;
IN
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
Z7' .
I
1:
2 i3 -t� I'll
�2�
TOWN OF BARNSTABLE j` o
LOCATION S? AZ L PA-r/� SEWAGE # qq.
VILLAGE /1'? In,f/L c ASSESSOR'S MAP&LOT ,3 -OAY
INSTALLER'S NAME&PHONE NO. t b I 0 Ce.e T/ r ?7 f0�)
SEPTIC TANK CAPAC=
LEACHING FACILITY: (type) _`� I Zf� L M4rO S (size) q"/I Y 9-
NO.OF BEDROOMS_ .
BUILDER OR OWNER I
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�, ..
� _
�� �
N.`� ' - �
/+J � `y
�.
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+n
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1.
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.. ��
C7
7
No. + Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer
es
.PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for )Digool *potem Cougtructiou Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System 71IRdividual Components
Location Address or Lot No. �5_,9 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel '0
Installer's Name,Address,and TeTelN(o. Designer's Name,Address and Tel.No.
64,0—,(,Aspel`T'}.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �2�iS1`� ,�DOO/� Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when a pli able
L r ee L/ 7'Ot,� .0 vac��
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has bewrTissued by this i Rear
Signed Date o+
Application Approved by a Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. d "lee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
-"" ZIpplication for Mizponl *p$tem Con!5truction Permit
Applicatio for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ElComplete System ttdividual Components.
Locatio Address or Lot No.'s� � ✓�'�" Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
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Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No-of>Persons Showers( ) Cafeteria( )
Other Fixtures ' �`"`�•._
Design Flow t�) gallons per day. Calculated daily flow 3�� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �1�PSG OQ Type of S.A.S. �5����I T i- • /L7��4Q.__
Description of Soil S
A
Nature of Repairs or Alterations(Answer when appl' able) 44- (/ ov /99i S� ,C'tf caT
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Date last inspected:
' Agreement:-
The undersigned agrees to ensure the construction and maintenance of the afore described'on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate.'of Compliance has b sued by this o ea '
_4 . - ,Signed /I Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(]/jam
Abandoned( )by k Q G A 0 EZ S R l t
at L W �� has been constructed in accordance
1 with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated
Installer I Designer 1
The issuance of this pel 't s ill of be construed as a guarantee that the system-Will function as designed.
Date P Inspector �( AI
u y v
r
No. 1 — ----------------------------Fee
191/
THE COMMONWEALTH OF MASSACHUSETTS
f PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mwi5po$ar *p5tem Construction Permit
Permission is hereby granted to Construct( )Repair )Upgrade Abandon( )
System located at '� L l
G �
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructio ust be completed within three years of the date o&spermrri it.Date: 7� A roved bfPP Y
f
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, oc� -e✓ hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at ��8 Aq tom" jai �f meets all of the
following criteria:
The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
6The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
/• There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
/If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
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B) G.W.Elevation 0 _+the MAX.High G.W. Adjustment _
D q
DIFFERENCE BETWEEN A and B 7/ '
SIGNED : DATE: f✓(-�� �
[Sketch proposed plan of system on back].
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THE COMMONWEALTH OF MASSACHUSETTS
BOARDgF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
.../.,o
d.........
Address
............. ...Onstaaler Address
04 Septic Tank-�Liquid capacity/in igalioKs Length................ Width---------------- Diameter................ Depth................
Z Other Distribution box ( ) Dosing tank ( ) I
----------------------------------------------------------------------------------------I--------_---_------
U ........................................................................................................................................................................................................
------------------------------ ........................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 19'Ned by the bjo� rd off�hhealthh.
ILignelL.4...... . ....... ... .....Lqo
Pate
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--''''-''--''-'-----------'------'— -----'—'—'— —
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No-----:� .7'------- Fine �:.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
A, I: 7 rr < .
Appliratiodi f yr lgi_qpooaI i8orko Tonfitrurtiort "motif
Application is hereby made for a Permit to Construct ( ) or Repair (. ) an Individual Sewage Disposal
System t:
;•. ... "f ,t ✓S- -4"�' „t °' , f ,ery .�.r`// J._LL 6 f f
f��ocn Addre V p f y for/I of l�o.
.,;r•t:f,ytj„ �.�""Y ma ..............: ....... Z44-..A..........................................
f t N Y3svxi` Address
......................... ......................................................
�wInstaTer Address
Q Type of Building a,, Size Lot............................Sq. feet
Dwelling�=' No. of Bedrooms..............n: .....................Expansion Attic ( ) Garbage Grinder ( )
PL4Other—Type of Building No. of persons............................ Showers — Cafeteria
0.1 Other fixtures ._..
d --
W Design Flow..................... gal n per person per day. Total daily flow.__.......�.................................gallons.
P Q p us Length................ Width............_... Diameter................ Depth................
W Septic Tank-/-Liquid ca acity - gallo
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........................................
Test Pit No. l...._------------minutes per inch Depth of Test Pit.................... Depth to ground water______-________._-____-.
w Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water........................
04 •-••-•-•-•............. --............. -
Description of Soil...................... Y,f:. ..r",mac, `......-•
1
U .--••-•--•---•----•---•--•-----------•--•••-•------••••--
W
, i --------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------•------•-----
VNature of Repairs or Alterations—Answer when applicable................................................................................................
•----•------------------------------------•-------......--•-------- ..............................................-------------------------------------------------------------------•-----------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ig.kfed by the board of health
,,,-;$igned.,1 . 'a ✓...... - ._;� r') {• _ _1
Application Approved BY........� r.._x' : ._ f. r' ✓/ f 1 t/' r <jf_: __ . t
f
.-•--- ----------•-•-
r Date
Application Disapproved.for the f ollowiny reasons-------------••-•-----_...----•-......_../................................................................
---------------•--•--.........---•---•-•------------•-----•----...---------..........---•--.._............_....-•----•---•---•-------------------•------ ......... •.... ................
/ �te
Permit No. Issued. (-- .. -- ..�..... .
at
e
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ...OF........f :, '�.. 'aY ."li:....>.............
.....
fIrrtifirtttr of Tootpfitturt
THY. I TQ CERT�FY�T hatAie Individual Sewage Disposal System constructed (L'`�ror Repaired ( )
by ' r N { , � p�. f == .�.......
41 at---""----v •�'=+ ---- --- -�`---�•---------�= =._-j-- -... .._-_--'"�"*�% f°-- ------lf'7 - '�-- --f--- -----' ---....>!�.h� ._e.......-r-�---- - r
has been installed in accordance with the'pr-ovisions of Article XI'of�ThedS e Sanitary Code as c]resct11 d in the
application for Disposal Works Construction Permit No_______ _______ ____a' _...�-r-_-__: dated. ___ _E -As
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
taw :� .... ;t ...... OF......... .. y `- '..::t,. '
.................... .......................
No....�.............:.... FEE...... .-:
• �i��o 1 �r�� � ���trtiott r�otit
Permission is.hereby.granted_.
t y
to Const�t.yf (, ') or Repair ��} an lndlv*lual S w isposal?System /
{ - '' F J...f!.�✓ .„ . '1 > f r;-r'( s�f/ i E�' /" _¢>./ '-'> �Z'�� A
at No.. 4..�....- f........ - �. ......Y�, C _. _, . . : ..! ............. ".F J.
as shown on the application for Disposal Wor Xs Constructiou, Poinit o.` �c71... Dated . . = 4.. .... .... "`:.......
0—i j/ //
..........................
u'erd of Health
DATE--------------------------------------------------------------------............
FORM 1255 HOBBS tic WARP.EN, INC.: PUS'LISHERS