HomeMy WebLinkAbout0504 MISTIC DRIVE - Health 504 MISTIC DR.
MARSTONS MILLS
/ A= 061 - 020
r
Commonwealth of Massachusetts'. O(al - 02U
Title 5 Official Inspection Form
,
,
J
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name /
information is
required for every arsons Mt Mills I✓ MA 02648 6-30-2.02
. • .� '
pace. CitylTown State Zip Code Date of §.P ePtiop ,
Inspection results must be submitted on this form. Inspection forms may n;ot,lie altergd jr>j' 1
way. Please see completeness checklist at the end of the form.
Important:When fillirg out forms A. Inspector Information
on the computer,
use only the tab JP Rutledge
key to move your Name of Inspector
cursor-do not JPRlnspect LLC _
use the return key. Company Name
345 Old Plymouth Rd.
Company Address
Sagamore Beach MA562
City/Town State Zip Code
508-237-1788 S1 14289
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with §#� on 15,14,9 0f Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the prgperty addrgs
listed above; the information reported below is true, accurate and complete as of the Xirge of My .
inspection; and the inspection was performed based on my training and experience ip:the proper fynetipn
and maintenance of on-site sewage disposal systems. After conducting this in ectign I havp de errpjned
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6-30-2020
Inspec o Signature Date
The s stem inspector shall submit a copy of this inspection report to the Approving Authority (Hoard
of Health or DEP)within 30 days of completing this inspection. If the system has�design fjov�Qf ,
10,000 gpd or greater, the inspector and the system owner shall submit the re
p
�,9,rt to the approrjate
regional office of the DEP. The original form should be sent to the system owner�pd copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspectlglp 1 ' Nader t
conditions of use at that time.This inspection does not address how s s.,e w e
p nk m (?�t lrn.
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
�y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 6-30-2Q2Q
page. City/Town State Zip Code Date'of 11 pctio.p
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 critOg Described
in.310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not eval,y; ted are
indicated below.
Comments:
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 apptoyed by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. It'not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether!geta�qr not) j structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is immirnpt system Will �sss
inspection if the existing tank is replaced with a complying septic tank as approve by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking aqd if q Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 2 of 18
z
cam, Commonwealth of Massachusetts
ry Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is
required for every Marstons Mills MA 02648
page. Citylrown State Zip Code Da101i1po'ectiop
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with l3paird of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in tl e distribution gox due
to broken or obstructed pipe(s) or due to a broken, settled or uneven di%ributioon box, System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NP Explain below):,
❑ obstruction is removed ❑ Y ❑ N ❑ NP (Ez,pl-in below;
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ MR (ExPjaln below):
❑ The system required pumping more than 4 times a year due to broken or gpstrgcted pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NP (Explain below):
❑ obstruction is removed E] Y ❑ N NP ((Explain below;
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Heatt ip order to deter(gine it
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordanpe,ith 310 Cll�lF,i
15.303(1)(b)that the system is not functioning in a manner which .T i� piote�ct putbJc`lhe�lth,
safety and the environment:
[5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systtem,,Page 3 of 18
c Commonwealth of Massachusetts
i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
504 Mistic Dr.
u
Property Address
Peter Jenkins
Owner- Owner's Name
information is
required for every Marstons Mills MA 02648 6-3q 2.0�,Q
page. City/Town State Zip Code Date`ofjnspection
C. Inspection Summary (cont.) x ,
j❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wet1,9,.I o salt
b. System will fail unless the Board of Health (and Public Water$uPli , if any
determines that the system is functioning in a manner that protects the 0,lublic hrealth,
safety and environment:
'❑ The system has a septic tank and soil absorption system (SAS) aqd ttroe.SAS is y4rith,n
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 Qf q public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet Offiyate water
supply well.
L] The system has a septic tank and SAS and the SAS is less than 100 flee,`:taut 50 feet pr
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 ja ;oratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen apd nitrpte nitroden 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:
Y PP Y
You must indicate "Yes" or"No"to each of the following for all inspectiprl
Yes No
❑ ❑ Backup of sewage into facility or system component d9 to �,verloade� or
clogged SAS or cesspool
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface vyaters
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
504 Mistic Dr.
v
Property Address
Peter Jenkins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-3g-2Q2�
page Cityfrown State Zip Code Datg Q,f dtl l q�
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 tiue to a[I oYefloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ❑ Required pumping more than 4 times in the last year NOlr due to clogged or
obstructed pipe(s). Number of times pumped: �.
❑ ❑ Any portion of the SAS, cesspool or privy is below high grgtrid water elevation.
❑ El Any portion of cesspool or privy is within 100 feet of a spr qqp water syp (y or
tributary to a surface water supply.
❑ ❑ Any portion of a cesspool or privy is within.a Zone 1 of a p4,blic water supply
well.
❑ ❑ Any portion of a cesspool or privy is within 50 feet of prlvate water syp ly well.
❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater tlian 5Q feet
from a private water supply well with no acceptable water quality aralysls, [Tis
system passes if the well water analysis, performer) at DEP eert 4
laboratory,for fecal coliform bacteria indicates abse(>t ipo theresenape
of ammonia nitrogen and nitrate nitrogen is equal t9 pr)gss than 5 ,
provided that no other failure criteria are triggered:A Co y of ttip analysis
and chain of custody must be attached to this ford
El El 10,000
system is a cesspool serving a facility with a design f lqW of 20 0 qp
10,000 gpd.
❑ El The system fails. I have determined that one or more of the above failyrg
criteria exist as described in 310 CMR 15.303, therefore the system falls. The
system owner should contact the Board of Health to deterrrljle what wide '
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must sgyp a, ecility with e
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the folio win g:!n addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water suoply
❑ ❑ the system is within 200 feet of a tributary to a surface, ,rjjq�qng water supply
❑ ❑ the system is located in a nitrogen sensitive area (lnterirp 1allhead Protection
Area—IWPA)or a mapped Zone II of a public water s�{pply well
�.._
35insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Dis pos,I System•page¢of 18v
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
�= r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l;
504 Mistic Dr.
V
Property Address
Peter Jenkins
Owner Owner's Name
information is Marstons Mills MA 02648 6-3Q-?-QQ
required for every - -�
page. Cityrrown State Zip Code Date'of tnsl a tlop
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is c9,psj0e„(ed a signjficut
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 SectlQn C.5of failed
under Section CA shall upgrade the system in accordance with 310 CMR �5;30� '�-he system pwner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspetCt'ons�
Yes No
® ❑ Pumping information was provided by the owner, occu .apt, pr Board of Health
® ❑ Were any of the system components pumped out in the pSeviqys two y�ees?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the sys�errt fecently or as part of
this inspection?
® El Were as built plans of the system obtained and examined? (If they were riot
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage bac�C up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located 9,,� bite?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of dgnstructjort,
dimensions, depth of liquid, depth of sludge and depth of gwgp,
® ❑ Was the facility owner(and occupants if different from oyyae[� pfovided�vjth
information on the proper maintenance of subsurface:, age disposal a r terns?
The size and location of the Soil Absorption Syste„ „(yz A: on the,sj a as
been determined based on:
,�,L � .
® ❑ Existing information. For example, a plan at the Board tof 1ealth.
® El Determined in the field (if any of the failure criteria related to ?art C is a4 Issue
approximation of distance is unacceptable) [310 CMR 15 30g,(.5)j
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
}P,. �{ W w
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
e � 504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is required for every
Marstons Mills MA 02648 6-3Q7202Q
page. Cityrrown State Zip Code Date of,I�ns00 tio�
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms�actuaj),: 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of begrooMs) 330
Description:
Number of current residents:
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
❑ yps No
information in this report.)
Laundry system inspected? yes No
Seasonaluse? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2019 578 gpd
2018 912 gpd
Sump pump? ❑ Yes No
NA
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
504 Mistic Dr.
Property Address
Peter Jenkins
Cwner Owner's Name
information is Marstons Mills MA 02648
required for every ,� , . •,�
page. City/Town State Zip Code Date gf`nspectiop
D. System Information (cont.) ry.f
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? ❑ `des P No
If yes, discharges to:
Industrial waste holding tank present? ❑ yes P No
Non-sanitary waste discharged to the Title 5 system? ❑ Yps ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner
Was system pumped as part of the inspection? ❑ Yes E N9
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'= 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
«. � 504 Mistic Dr.
L
Property Address
Peter Jenkins
Owner Owner's Name
information is Marstons Mills MA 02648 6-3Q-202�
required for every ,.
page. City/Town State Zip Code Date'of 0mo0ti9p
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 cecofds, if epy)
❑ Innovative/Alternative technology. Attach a copy of the currept operation and
maintenance contract(to be obtained from system owner)pn dopy of latest
inspection of the I/A system by system operator under contract f
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? yes E No
5. Building Sewer(locate on site plan):
Depth below grade: 3feet
Material of construction:
❑ cast iron - ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: NA
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage pisP oral System•Page 9 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 504 Mistic Dr.
V
Property Address
Peter Jenkins
Owner Owner's Name
information is Marstons Mills MA 02648 6-3 -202
required for every � ,.. . .,�
page. Citylrown State Zip Code Date of hp.spectiori
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylerge, 0 other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Ye§ Ej No
5X5X
Dimensions:
Sludge depth: 4 ft
Distance from top of sludge to bottom of outlet tee or baffle 0
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 10'I
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Measuring stjck
,.. , ;•,,
Comments (on pumping recommendations, inlet and outlet tee or baffle cq%tio{�I structyral integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
All Components appeared to be in good shape at time of inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
504 Mistic Dr.
v� Property Address
Peter Jenkins
Owner Owner's Name
information is Marstons Mills MA 02648 6-30 20_�
required for every Q
page. Cityrrown State Zip Code Date Agt InSpectio�l
KR
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(ex laia):
�,.
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 corldjtjont structural jnteglj$y,
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 sjte planj:
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene P 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 j8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
C � 504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is Marstons Mills MA 02648 6-3 -202
required for every
page. City/Town State Zip Code Da;e of�nspectiop
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No.
Alarm level: Alarm in working order: P 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? IEJ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
Comments (note if box is level and distribution to outlets equal, any evidence pf solids carryover, any
evidence of leakage into or out of box, etc.):
D box has only one outled and had no evidence of solids carryover.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-3Q-202,
page. City/Town State Zip Code Date of Insper nction
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ Flo*
Alarms in working order: ❑ yes ❑ N9*
Comments (note condition of pump chamber, condition of pumps and appWrtppn noes, 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, dimensjoi9s:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: 6 X 6 leaching pit
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
f
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-30,-2020
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, darqp soil, eongition of
vegetation, etc.): t``
No evidence of leaching pit being any more than 1/2 full
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site Phan)
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_, 0o
Comments(note condition of soil, signs of hydraulic failure, level of ponding, cgndition ofeetion,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I4 of 11
C Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M � 504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-3(J-?02Q
page. City/Town State Zip Code Date'of rnspectiop
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 ve etation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
7
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-30-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) r.
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 pyb(jcwter staply enters
the(building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
D� ��S�s
-7.3
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page t6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
504 Mistic Dr.
Property Address
Peter Jenkins
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 6-3Q-2p2(J
page. City/Town State Zip Code Datq qj gnspgction
ra
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Greater than 4 feet
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 ofAS)
❑ 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:
Tank was empty, used auger to depth over 4' below tank
Before filing this Inspection Report, please see Report Completeness C4eg,k ist on „Text gage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Dispose I Sysjem•page 17 of 18
M
c Commonwealth of Massachusetts
.try Title 5 Official Inspection Form
i,
r, Subsurface Sewage Disposal System Form -Not for Voluntary AssessmenXs,
/ 504 Mistic Dr.
Vl Property Address
Peter Jenkins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-30-2020
page. City/Town State Zip Code Date of Inspogtion
E. Report Completeness Checklist r..
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 SysY@m•Page 18 of 18
No.wI / Flnc..... .. .�
THE COMMONWEALTH OF MASSACHUSETTS
OpeRD SALT
....fl F.........75A
Appliratiuu for Uiipnsal Works Tomitrttr#ion Prruti#
Application is hereby made for a Permit to Construct (` or Repair ( ) an Individual Sewage Disposal
System at:
...A<...I jrkMT Ns./MAIF.............. .....................................:....•----------.....-.
Location-Address 80 or Lot No. to
.P114!��.................................. 1 .-�0--:.. ..........
Owner Address
..........bA.4 O••••-•.....0 a a.TZ'A... -;r i------------- ---------•----
In all r Address
Type of Building �av Size Lot.....
41.0.0-0.......Sq. feet
U Dwelling—No. of Bedrooms........... ...........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ....................... ---------------•--....
W Design Flow............................................gallons per person per day. Total daily flow........................................_...gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_----------------- Diameter.................... Depth below inlet..........:......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ---------------------------------•••---------._............---•---•-•-•----••--•---..........---•------......--•---------...•......•••-••...............-•--
O Description of Soil...............................................................x --------------
•--•---------------------------------
.....................
V
"j
W ....••••---•------•••--------•••-••---•--•----.......-•••....................•--•-•-••-••-••••••..... - ------•----- -------•--•-•-••- .
UNature 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 iITL U 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been sued y the board of health.
Signed ---•-•••._-•_ •.�...... -_.
Va
Application Approved By •••...--•--••-•---•.....................•-•...... ...•....
Application Disapproved for the following reasons-.......................................................... ...................................................
..................................................... .......---•--......-•--------•--•._----•-----•-•-•-•-......•••........•.............-----------------•-•--... ......-••••-
Date
Permit No..� Q �
S.1 .-•- - ---• ---------•--------------- Issiled.......................................................
No `:...... lI Fps.... �''. ....
THE COMMONWEALTH OF MASSACHUSETTS
OARD F E LT
rOU4 ...... - _ _.__
Appliration for Disposal Works Tons#.rur#inn Frruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
C.:... ! v5.t�11.��j.............. ........ - -.... ...................................-----.......-•---...................
Location-Address or Lot No
.....Pt.I�N..AC ......... S�1.►-P.i_AA._�_�.................••-••-............_ . .I�. ._....40/..:�.? .C�7VT?�{Y!L�E�..14 A.---.........
owner Addres
- / ,ft o NA/Mov .N A..._.02r01.. ..............
Q T" q .... ... . ............... s '...... i - ------ -- -
In tal er Address
U Type of Building ��✓i ��� `�� Size Lot..__ y�D O Sq. feet
U Dwelling—No. of Bedrooms___.........3............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of ersons____________________________ Showers
� YP g .............•-•------------ P ( ) — Cafeteria ( )
Other fixtures . ----------
W Design Flow........................:...................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._._._____.____..___...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --•----------•-•----•-••••-•_____________________________••----_____......._.._...__________......__.........................................................
0 Description of Soil..............................................................._. __-• ____..... - __-- ......._. .. .....................................
W
UNature of Repairs or Alterations—Answer when applica ..........................._i___.._...__.____..___......:._...............__..__..........._..
....... ........•-•-----------••-•--......-•------•----------•-------___..__........_._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordance with
the provisions of TITI.i 5 of the State Sanitary Cod .The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been sued y the board of health.
lSiigned C.-.-. .................
•---•-••-
APPlication Approved By.... : __________-.. . .................................................. -... ;��••-•-•J-
t6��..............
•' Date
Application Disapproved for the following reasons:..........................................................................................................___
...............................••-: - ...----------
.......... .....•. Date....... ---
Permit No. � -___________________ Issued --------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
��/ 0�4RD HEM
THE
............... V.... ......OF.........-: .. .... ..'`,?.......................................Z_ _
(Inr#if irate of Toutpliana
by• THIS 1 T IFY, That the Indivi �ewagDisposal•Sys constructed ( or Repaired ( )
.••••-
/ �� ?1 / Installer �i
f ._.
at.. -•-.:. / . ....... � ... ........ .:r:�_.�a...- ._[._!.i.. -._....--•--L •..-•-••-••••••••••••-•••••-••--•.....••••••-
has been installed in accordance with the provisions of TIT of T�j e qte Sanitary Coded de r n the
application for Disposal Works Construction Permit No........�`�.�C:?.:.� .... dated_........,:` __f ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................... f7lL.1.8•-•••••••-•••••-••--••--.......... I Inspector........--••••••••�.... ..................................................
THE COMMONWEALTH OF MASSACHUSETTS
W.OF........
No..d .....()/f .................. FEE-•4,:_............
Dispoo P o,k Tono#rWiott f ernti#
Permissioni hereby granted........ ...--•-•-••.---•----•-•-•••.............•••••-•••••••--•--.. ...-••-•___............................ ...
_.
to Construct (, ) or Repai) (/ ) anIndividual-Sewage is? Sys o f/G j
at N
._ ._. _. .. --
as shown on the application for Disposal Works Construc Perini o:: ': ated.... ._L. .. ..............
.......... ...... ..... ..................................
DATE.............. Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
l - Y
41 S TOWN OF BARNSTABLE
LOCATION e_oe Jgr CC JSvY M i_5r � � SEWAGE #2 - 1l
VILLAGE ASSESSOR'S MAP & LOT-apl-000
�
INSTALLER'S NAME & PHONE NO. (7av;c/ C
o/ag20 3�i8l063S
SEPTIC TANK CAPAC.ITY�/piny acL n._
LEACHING FACILITY:(type) eo-' r (size) /doo ra'01�
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER i�u6l•�
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED_ rJ/
VARIANCE GRANTED: Yes No ��
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