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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments"+
19 Hilltop Drive ,
Property Address
Joseph Keating
Owner Owner's Name -,
information is Marstons Mills Ma 02648 11/12018
required for every .
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
11
9 Company Address
Centerville Ma 02632
City/Town State Zip Code
r � 508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
11/1/2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 19 Hilltop Dr Marstons Mills is served by a Title V septic system consisting of
a 1500 gallon septic tank, distribution box and a 20'x22.5'x1' perforated pipe leach field. The system
was found to be in proper working condition at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
Supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
PSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 333 gpd
provided
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
Original system installed 4/18/2007
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. 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.):
Joints ok, no leaks or blockages. Vented through roof
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is Marstons Mills Ma 02648 11/1/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.5
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: 1500 gallons
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was recently cleaned and does not need to be done now. Water level was even with outlet
invert. Tank was structurally sound and not leaking. Outlet cover is on a riser.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is Marstons Mills Ma 02648 11/1/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date:of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
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.):
Distribution box was video inspected and found level and in good condition with no rot. Water level
was even with outlet inverts with no signs of past backup.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 20'x22.5'x1'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1P
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
s.a.s. consists of a 20'x22.5'x1' perforated pipe leach field. No signs of past hydraulic overloading.
Soil and stone within field was probed and was found dry with no signs of past saturation.
12. 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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page.- Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
TAB 1 Z 3
3t Z? �
AZ
L33 3�
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
1' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. City/Town I State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 5-11-2006
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
design plan dated 5-11-2006 indicates that no groundwater was encountered at 120" and system is
designed to have 5+' seperation between bottom of s.a.s. and adjusted groundwater elevation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Hilltop Drive
Property Address
Joseph Keating
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/1/2018
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Town of 1Barnstable P# �'
, r
Department of.Regulatory Services
> ' Public 11ealth Division Date
r�
200 Main Street,Hyannis MA 02601
pEEO MP'1 t
Date Scheduled / / /
i Time _ Fee Pd.
i
Foil Suitability Assessrhent for Sewage Disposal
Performed By: lJ J Witnessed By: - f �
)—
LOCATION& GENERAL INFORMATION
Location Address J Owner's Name�G<E j
/ �7� /p l���l/L' Inl Address
Assessor's Map/P4rcel: d 17 e2 e-Ir �i 1 j Engineer's Name )/If
NEW CONSTRUtl.',l'ION L/ REPAIR Telephone#
r i
Land Use /` Slopes('%) `Z Surface Stones
I
Distances from: Open Water Body�ft Possible We.Area Orl ft Drinking Water Well _Z_j_�ft
Drainage Way F ft Property Line 1 f7_ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
141
E i N.)
i
\ Parent material(geologic) — Depth t0 Bedrock
i
Depth to Groundwatdr. Standing Water in Hole: Weeping from Pit Face.,
i
Estimated Seasonal:High Groundwater
tTERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used. Ie. 1�IV\
Depth oiwe pi Landing to obs. le: n, Depth t0 sail mdjusit ,.—ni—
Depth to�weeping from side of obs.hole: n. Groundwater At�uBtMent m ft.
Index Well#_ Reading Date: Index We *V ---. =—,
AdIJRlor� Adl.0ltlund terLgv+<I,,,a /\
� 1
PERCOLATION TEST vjitt
• i
Observation I Tinto at 9" _..._...
Hole#
Depth of Perc 4 b ��I I Time at G'
Start Pre-soak Time.O 11 '� I 1`.q/ Time(9"-6")
End
Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed; Additional Testing Needed(Y/N)
Original: Public Hehith Division Observation Hole Data To Be Completed on Back-------
. ***If percola#on testis to be conducted within 100' of wetland,You must first not'�1'the ,
_ _ _ .r..._.._._.....l..hnn:ewreinv-
`DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil ther
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
DEEP OBSERVATION HOLE LOG. Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil er
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consi tenc %Gravel
�.
;DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc Gravel
-DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc Gra el
Flood Insurance Rate Map:
Above 5160 year flood boundary No_ Yes
Within 500 year boundary No Yes
within goo year flood boundary No Yeses
Depth of Natutatly Occurrin Pervious Material
Does at least fo feet of naturally occurring pervious teri al exist in all areas observed throughout the
area proposed f6r the soil absorption system? 1
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on. (date)I have passed the soil evaluator examination approved by the
Department of nviro mental Protection and that the above analysis was performed by rqe consistent with
the required training,exp rtise nod experience described in 310 CUR 15.017.
Signature Date _A D L
Q:SEfTICtPERCVORM.DOC
1
i
TOWN OF BARNSTABLE
LOCATION 1 ��11 �� SEWAGE# ICJO(,-
VILLAGE
�+��+.nS AWS ASSESSOR'S MAP&PARCEL 02/(&
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY Nt5W
LEACHING FACILITY. (type) T�r�rr.�r "�� (size) ?-0) 22.G .4 1
NO.OF BEDROOMS
OWNER
PERMIT DATE: S-23- Q6 COMPLIANCE DATE: / r..
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 Y G
LA
I(DLA
As,
2-us
Wei.#
. lC� � �,,,,•�' Fee
No. �
s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION= TOWN OF BARNSTABLE, MASSACHUSETTS
application for igpo!5a[ 6p!gtem Cow5truction Perron
Application for a Permit to Construct(/ Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. )CJ J��'/�� �V'i_'+ M)0, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 4p '— � � 4 n Z1248 ;))1( A
Installer's Name,Address,and I.No. Designer's Name,Ad ress and Tel.No.
Type of Building: DStyL, t 3 /)/y j ✓ " '.
Dwelling No.of Bedrooms of Size V O / sq. ft. Garbage Grinder y(S
Other Type of BuildingslfilL• AAr fftfe No.of Persons Showers Cafeteria( )
Other Fixtures
Design Flow(min.required) -_ 3—5 gpd Design flow provided gpd
Plan Date ' i`'gV'0' Number of sheets Revision Date
Title
Size of Septic Tank (sA —,'LQ Type of S.A.S. U to
Description of Soil M h Q -, '54110
Nature of Repairs or Alterations(Answer when applicable)
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 Certificate of
Compliance has been issued by this Board H
-- _ y1 h,7
igne Date
Application Approved b _ :Date
Application Disapproved:by: Date
for the following reasons
Permit No. 6 Date Issued
No. . s -leJ n Fee
,r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC.HEALTH D:IVISIGN TOWN OF BARNSTABLE, MASSACHUSETTS Yes
" App Ytcatt0u for t5o5aY �p5tetn CottgtructtotterrrYtt
Application for a Permit to Construct(V Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
) i
Location Address or Lot No. i-//� 1 )*H �)0 I V L, 10,)0, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcels 7 -7 ��q�_ hi.��Z r,r�s ;IIr I�i vaGy�
i
Installer's Name,Address,and 1.No. Designer's Name,Address and Tel.No.
77 SS*Z—AA</,►510alef 16q Rras 1::A&,�,A .
E
Type of Building: �Sty� r 3 Gj�r;/ TF
DwAin . No.of Bedrooms 'Lot Size • s .ft. Garbage Grinder
g _ q g (No
Other Type of Buildings/zf,/L f Vft:LftSa No.of Persons Showers Cafeteria( )
Other Fixtures
Design Flow(min.required) 7) gpd Design flow provided T33 gpd
Plan Date Number of sheets -- Revision Date
Title
Size of Septic Tank 6A Type of S.A.S. 2 lcf P2, 5- y?00
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /Vi= 15V5'lr�
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 Certificate of
Compliance has been issued by this Board df ealTh. /3
igne Date /I--
Application Approved b t }Date
Application Disapproved by: j , Date
f 6r the following reasons
Permit No. - ) Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, at the
�On—site Sewage Disposal System Constructed ( .......Repaired ( ) Upgraded ( )
Abandoned(
at \ ' C, YYN has been constructed in accordance
with the provisions of Title 5 aJ the for Disposal System Construction Permit No.D CC 6 O Gj dated
Installer Designer f 0-
#bedrooms Approved design flow cS-,=9 - gpd
The issuance of this permit shall not be/cnoonnstrued as a guarantee that the system wili`ll-function> designed.
Date �(_ / Inspector �"� -a
——------------------------------------------
No. �-�+.JQ P ""' -��, .� Fee
THE COMMONWEALTH OF MASSACHUSETTS "
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
Migogar 44pgtem Cou!gtructtou Permit
F
Permission is hereby granted to CQr}s TO
( Repair ( ) Upgrade ( ) AbandonSystem located at 'I ► r y ;.
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
Al-Provided: Construction m st be co leted within three,years of the date�ff this pie i
Date Approved bye_
05/02/2007 10:49 5085403344 JELANDERS PAGE 01/01
Town of Barnstable
Regulatory Services
d• Thomas F.Geiler,Director
1� tt�r►sra>� �
lit
"9; ��� Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: b -Z - - Sewage Permiit0-10e6 `v_2 3FAssessor's MaplPareel 0
Resigner: LA
Installer:
p
Address: �•0• Address: j/,S`_.'zV YCY
V ►o l� VZ574f 4W/4,
On _—,2 3~�t°� d�f` ��)` was issued a permit to install a
(date) (installer)
septic system at 1 'k. based on a.design drawn by
y r ( o ss)
.,J. .ro dated 240 t v. . t4A, i�I Zd'i i.
�( esiigner)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify, that the septic system referenced above was installed with major changes (i.e.
greater than 1 W lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow.
� - ���1E1 OF ►��"'Ntt.
(Ins et's Signature) 4f"�r7
JOHN
NDES
CIVIL _,M1
NO,35701 �
(. esigner's Signature (AM Here
PLEA ETURIY T 'STABL U LIC a
EALXFJ DIVI i�. CE.RT[Fl O
r iF
COMP rsCE WILL NOT BE IS IED UNTIL BOT IS FORM A AS-BUILT ItD ARE
RECEIV Y THE BAR TABLE PUB C HEALTH DIVI5ION. THANK YOU.
Q'Hu,Ith/SeptieJDnisner Certification i'orm 3-26-04.doc
G RAr t iC SCALE ARSTONS MILLS
40 0 20 40 80 160 \' +�
VENT PIPE WITH �f 0
RODENT SCREEN A
( IN FEET ) LOT 1
1 inch - 40 ft.
BENCHMARK
y G� TOP OF CB
0
WO
ILEV. 116.j
200' OFFS TREDGE LIMIT EDGERIVER r �C , ,P / ASSIGNED
xd\ ,I�
ti
r .a 109.34 s'08 ;� 114 �116
�
��104�
LOT 2 �o
20,000 S.F. O
O s 0 A N ROUT
1 G
N�w S.
�94 10 1°a, °'f' cn 00.00 LO US
�o y �0
sz s o
Nam: 90 — 90 ° a6 LOCUS MAP
88 \\ PLAN REF 272-10
` DEED REF 20573-109
` ra' * FIRST FLOOR = 117' WITH 12' HIGH "
ss B6 \ `° REINFORCED CONC. WALL ZONING. RF
A-A SETBACKS.• 30'-15'-15'
-A'�o o FLOOD ZONE- "C"
, B4 0�'`%, PANEL NUMBER. 250001 0015 C
o,�'� / `� / �9�c�,os DATED.• 08-19-85
s PLOT PLAN OF LAND
°,� / �9�� LOCATED AT.•
�° 19 HILLTOP DRIVE
MARSTONS MILLS
air PREPARED FOR.-
MICHAE'L KEA TING
MAY 09, 2006
BISF- BOARDERING LAND SUBJECT TO FLOODING
STILL WATER AREA ACTING AS FLOOD STORAGE AA HIGHEST OBSERVABLE FLOODING AS OF 5/11/08 '►►�L�N OF�irSSdfs �` OF qgq� REV.• MAY 11, 2006
c �E 9F� yGs o� HN s REV
e STEPHEN 1 r LA IILEY �,
J. REV
c� ► o` i r
1{ a DOY E s v }
#37559 a .35101 :>
✓F__s ts YANKEE LAND SURVEYORS
S,1 & CONSULTANTS
►1q � ��y��4
P.0. BOX 265
UNIT 1, 40 INDUSTRY ROAD
MARSTONS MILLS, MA 02648
TEL• 508-428-0055 FAX 508-420-5553
SHEET I OF 1 JOB /.- 54060B JF
w•
F.F. ELEV.=118_0(: r. ,. ,
N
• VENT PIPE
20 m1n.
ELEV.= 116.1 WITH ORENC
j ELEV.= 111.0 CARBON
4" CAST IRON OR CONCRETE COVERS`
SCHEDULE 40 P.V.C. `\
4" CAST IRON OR 4" DIA. SCHEDULE 40 PERFORATED PLASTIC PIPE
SCHEDULE 40 P.V.C. 5MANIFOLD TO VENT PIPE
DIST.=10_5_ SLP.=0.02_ . SLP.=0•,005 12" A lj8" /2 of
INVERT CONCRETE COVER DIST.=1 WASH STONE
FLOW LINE DIST.=38.5' SLP.=0.02 ___ 0"0"0"0" ..o..o,.o,.0..0..0,.0,.0..0..0..0.,0..0,0,.0 O" 0"0"0"0 0"0"0"0"0-0-0" owo-o-
ELEV.= 111_0 ELEV.= 110_7 — _ INVERT ELEV.= 109.5 000ouo jo 0000000000000000o0000000000000o000o0o0o0o0 0o000000000o00 0o000�
— 10" MIN. 19 — _o_o_o_o o_o_o_o_o_o_o_o_o_o_o_o_o_o_o_o_o_o_o_o_o_ _o_o_o_o_o_o_o _o_o_
110.54 o u o( 6" LAYER OF
THE LENGTH OF ELEV.=____ ELEV.= 109.7: —' ELEV.= 109.60 ( o . /a" To I-1/z"
DEyTQERIINED TEE IS
4" CAST IRON OR �O�OvOvOvOvOvOVOVOVOVOVO('. �O0Wo
UVOVOVOVOVO0OCWASHED STONE
THEITANK USEDF scHEDULE ao P.v.c. DISTRIBUTION BOX �.,o�0 0 0 0 0 0 0 0�0�0�o� oo„o„o„o„o„o- ELEV.= 108.9
,y (SEE CHART AT RIGHT)
LENGTH OF USE H-20 LOADING USE STONE
1500 GALLON SEPTIC TANK DE TIH BELDWLFLOWELINE TO BE WET TESTED IF
4 FEET........14 INCHES MORE THAN ONE OUTLET. TO LEVEL THE 25'f
TO BE PLACED ON 5 FEET.-.".'." INCHES BED AS NEEDED.
6" OF STONE OR 6 FEET........24 INCHES TO BE PLACED ON
MECHANICALLY COMPACTED SOIL. SEE 310 CMR 6" OF STONE OR
15.227 (6) MECHANICALLY COMPACTED SOIL. BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV =84*_
USE A TANK WITH THREE COVERS. *ELEVATION 84 EXISTS ON THE LOT
SOIL TEST DONE BY: STEPHEN J. DOYLE
WITNESSED BY: DON DESMARAIS ____________ WITH NO VISABLE GROUNDWATER
PERCOLATION RATE: __2---MIN/INCH P# 11263 a• �11YE/R� of
TEST HOLE 1 DATE: 4L14106 _ ELEV.—Hl8___ "0"0"0 "0"0 "0"0 fi�sxg'6 3TONe
8' YER OP
�o���O O�� O 3/44r► 1-1/2'
PRO FILE OF DEPTH HORIZON TEXTURE COLOR MOTT. OTHER o 0 0 .,�H STONE
SEWAGE DISPOSAL SYSTEM 3 PERFORATED PIPES
NOT TO SCALE 0"-6" A SL l0YR 3/2 SECTION A-A
I HEREBY THAT 1 AM A
CERTIFI ATOR IN THE
CoM O S,ACHUSETTS,
GENERAL NOTES: s"-3o" B LS lOYR 5/8 SQ O ytVA FOR THE
PERC ® ��
_
1. THIS PLAN IS FOR THE CONSTRUCTION OF A NEW SEWAGE DISPOSAL SYSTEM. 46 {� o.3 N -
„ � 5 10101
2. PLAN REFERENCE LOT 2 BARNSTABLE REG. OF DEEDS.
3. THIS PLAN IS FOR THE INSTALLATION /REPAIR OF SEPTIC SYSTEM 30"-126" C MED. SAND 2.5Y 6/4 o� ISTf
AND NOT TO BE USED FOR SURVEYING AND ZONING PURPOSES. NO H2O T :^ DATA:
4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. ENC'D
TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS I NUMBER OF BEDROOMS
FOR THE SUBSURFACE DISPOSAL OF SEWAGE. TEST HOLE 2 DATE: 4L14L06 _ ELEV._1L4-0__
5. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN GARBAGE DISPOSAL NONE (9)-_____
12" OF THE FINISHED GRADE. DEPTH HORIZON TEXTURE COLOR MOTT. OTHER
6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE TOTAL ESTIMATED FLOW -a3Q----- GPD
SAME, UNLESS NOTED BY FINAL CONTOURS. 0"-6" A SL 10YR 3/2 ( 11(L__ GAL./BR./DAY X -2---- BR. )
7. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE
OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR SEPTIC TANK CAPACITY 150-0-SAL__
WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING
SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING LEACHING AREA REQUIREMENTS
f° AREAS UNLESS NOTED. 6"-30" B IS 10YR 5/8
8. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL PERC ® SIDEWALL AREA 0____ S.F.
±� BE MORTARED IN PLACE. 48" BOTTOM AREA _4S2___ S.F.
9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO LEACHING CAP.(BOT. & SIDEWALL)_ 333 _ GAL.
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 30"-120" C MED. SAND 2.5Y 6/4
10. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF NO H2O RESERVE LEACHING CAPACITY _333____ GAL
ALL UNDERGROUND UTILITIES PRIOR TO ANY EXCAVATION. ENC'D
APPLICANT: JOSEPH KEATING DATE: 05/09/06
REV.: 05-18-06 I SHEET 2 OF 2 IJOB # 54060
a.