HomeMy WebLinkAbout0683 MISTIC DRIVE - Health 683 Mistic Drive
- Marstons Mills
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DEC rpnyvealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
VtLA Company Name
155 George Ryder Road South
Company Address
B Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
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:
® Passes �X,SNOFM,a ❑ Conditionally Passes ❑ Fails
❑ Needs er MIRati the Local Approving Authority
D.
O COU A OWR N
0.1 28
December 1, 2016
Inspector's Sign erFM �allctbmit
Date
The system inspec or 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts i
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
683 Mistic Drive
7M
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
page. Cityrrown 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:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
Removal of garbage grinder is recommended
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 exfiltrat on'or tank,failureris imminent. System will pass
inspection if the existing tank is replaced with a complying septictank.as approved by the Board of
Health. fr',
*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 My..ears.old.Js:available.
El Y ❑ N. ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
regjir dfo is Marston Mills MA 02648 December 1 2016
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
683 Mistic Drive
�M
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
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 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
4 u - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
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.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G„M
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1, 2016
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?:,
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® 1-1 information on the maintenance of subsurface sewage disposal systems?
proper 9 P y
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.
® 0 Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CM 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 gpd
t5ins,doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is Marston Mills MA 02648 December 1 2016
required for every
page. City/Town State Zip Code Date,of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
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 ears usage d 421 gpd
9 ( Y 9 (gpd)):
Detail
2014: 163,000 gallons 2015:174,000 gallons 2016 (first half): 47,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of,17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form -
" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1, 2016
page. Cityrrown 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: owner
Was system pumped as part-of the.inspection? ' El Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Y
® 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.doc•rev.6/16 "Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'M 683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
infcrrnation is
required for every Marston Mills MA 02648 December 1, 2016
pace. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 5+years Certificate of Compliance for a new leaching system was issued 3/10/2011 (Permit#
2011-043 at Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (.on condition of joints, venting,.evidence=of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: less than 1
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:
8.5' x 5'x 6-1000 gallon
Sludge depth:
3 inches
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1, 2016
page. Citylrown 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 31 inches
Scum thickness 3 inches
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 12 inches
How were dimensions determined? As built card
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not requireded at this time. Maintenance pumping is recommended every 2-4 years with
year round occupation and removal of garbage grinder. Tank and tees appear structurally sound and
functioning as�intended. No evidence of leakage in or out was observed..
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
t5ins.doc•rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1, 2016
page. Cityrrown 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 ❑'polyethyle`ne - ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
683 Mistic Drive
M
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1, 2016
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 at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No adverse conditions observed.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ 'No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
1f SAS not located, explain why:
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 1
❑ 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.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed.A bucket of water was poured into the distribution box and was observed to pass through in
a rapid and unobstructed manner, and could be heard splashing down into the infiltrator units.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1, 2016
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.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
page. Cityrrown 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
LEACHING IN �p
GALLERY Fr®-TEC .U __
4
DISTRIBUTION BOX
THIS SKETCH IS
BEST VIEWED IN
COLOR FORMAT
2 L Oo CA T§Oo NS
1000 GALLON —OF SEPTIC COMPONENTS
SEPTIC TANK
I —DISTANCES IN DECIMAL FEET
A B
B A
1 47 38.5
LDWELUNG
TING 2 44.5 44.5
3 62.5 49
4 83 62.5
83
NOT
TO
SCALE
PAVED DRIVEWAY
U�
508 364-0894
hM§SS T§C DR§ V/L
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
L
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high groundwater: 11.5+
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:
Soil log of 2011
❑ Checked with local excavators, installers -(attach documentation)
I
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Soil log of 2011 shows no mottling or groundwater to a depth of 11.5 feet in a witnessed soil test log
on file with Health department.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth,&Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
683 Mistic Drive
Property Address
Andrew L. and Kelly D. Bolam
Owner Owner's Name
information is required for every Marston Mills MA 02648 December 1 2016
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
GEOHYDROL OGI CAL PROFILE,
- NOT TO SCALE
Z
a
J
C
2
W
Z
0
BOTTOM OF
LEACHING
PER DESIGN
'PLAN
LEACHING IS �,,
ABOVE HIGH .�
GROUNDWATER
NO GROUNDWATER
MOTTLING NOTED
ON DESIGN PLAN
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable Barnstable
SHE
T° - BS.L1.L1
i '�
MASS. °� ft
Regulatory Services Department 1 AlMm�ca�V
9 -
i639• ♦e
Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX:. 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7008 3230 0002 5178 2282,
February 17,2011
Mr. Albert Kvicala
683 Mistic Drive
Marstons Mills,MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located 683 Mistic Drive,Marstons Mills,MA was last inspected on
2/07/2011,by Robert Paolini, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system"Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00)due to the following:
• Liquid depth in cesspool is less than 6"below invert or available volume is less
than'/2 day flow..
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action. ,
OF OARD FHEALTH
t
Thomas McKean, R.S., CHO.
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\53 Uncle Willies Way,Hyannis.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is Marstons Mills Ma. 02648 1/25/2011
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 A. General Information
_
forms the ��♦�/,,,f
computer,
r,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not use the return Name of Inspector
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)477-8877 S14454
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
❑ Passes ❑ Conditionally Passes Fails
❑ Needs Fu her Evaluation by the Local Approving Authority
1/25/2011
Ins ctor's Si nature Date
The system inspector shall submit a copy of this inspection report to the Approving Authorit�%(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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
•R
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. Cityrrown 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:
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
. s
Commonwealth of Massachusetts
Title *5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. Cityrrown 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 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
❑ ® clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins-111'0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
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 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
.❑ 13 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r,
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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
2009:153,000
Water meter readings, if available(last 2 years usage(gpd)): 2010:156,000
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1/25/2011Date
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
P
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. Cityrrown 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspecti
on Form
f r Voluntary Assessments
Subsurface Sewage Disposal System Form-Not o ry
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is Marstons Mills Ma. 02648 1/25/2011
required for State Zip Code Date of Inspection
every page. Citylrown
D. System Information (cont.)
r Approximate age of all components, date installed (if known)and source of information:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1611
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
10'+
Distance from private water"supply well or suction line: feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Joints appear tight No evidence of leakage System vented through the house vents.
Septic Tank(locate on site plan):
101.
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
1000
Dimensions:
3„
Sludge depth:
Title 5 otricial Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
t5ins•11/10
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required`or Marstons Mills Ma. 02648 1/25/2011
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
29"
2°
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
Measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
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
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owners Name
information is Marstons Mills Ma. 02648 1/25/2011
required for
every page. Cityrrown 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
t5ins-11MO Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1111 of 17
6
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. Citylfown 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 Ievel.Box has one outlet lateral.No evidence of solids carryover.No evidence of leakage.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
c
' Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type.
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.System shows signs of hydraulic failure.Water level was up to invert at time of inspection.
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is Marstons Mills Ma. 02648 1/25/2011
required for State Zip Code Date of Inspection
every page. Cityrrown
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.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
t5ins•11/10
Commonwealth of Massachusetts
Title 5 .0fficial Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. Cityfrown 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
0
3 -BSI•�'` ,s
46
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A
yr , 14
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t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 1/25/2011
every page. CityfTown . State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Bottom of LP 40'
Estimated depth to high groundwater: 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
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official InspectionForm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 683 Mistic Drive
Property Address
Albert Kvicala
Owner Owner's Name
information is Marstons Mills Ma 02648 1/25/2011
required for /Town State • Zip Code Date of Inspection
every page. Y
E. Report Completeness-Checklist
Inspection Summary:A, B, C, D, or E checked
®Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
t ® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I t5ins-11/10
4
t " "
TOWN OF BARNSTABLE
LOCATION 10r,v{ SEWAGE# a ®GI — 0 413
VILLAGE . ASSESSOR'S MAP&&PARCEL
INSTALLER'S NAME&PHONE NO. �G• mot /r/<oo-�S'
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) X,
NO.OF BEDROOMS
OWNER q
PERMIT DATE: _/-// COMPLIANCE DATE:
Separation Distance Between the: If
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
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TOWN OF BARNSTABLE
},LOCATION fe 8� �,f�� pD�SEWAGE#
VILLAGE ;Z&JW4&,& "SSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)NO.OF BEDROOMS
OWNER 0 �\
PERMIT DATE: MPLIANCE DATE:
Separation Distance Between the-
Maximum Adjusted Groundwate ��b�l��tothe 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
' tf TOWN OF"NSTABLE q
LOCATION r1C SEWAGE
VILLAGE I�Ar6A)J- Z&e<, ASSESSOR'S MAP & LOT( 7�
INSTALLER'S NAME & PHONE NO. DLC6
SEPTIC TANK CAPACITY 14VO 6?gel
LEACHING FACILITY:(type) j /&90 46eI, (size)70 /5 Iw'
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER ,
BUILDER OR OWNER Y6-1ue Acme)w6 a
DATE PERMIT ISSUED: INSPECTION
DATE COMPLIANCE ISSUED: ''`
a � y
VARIANCE GRANTED: Yes No ��
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117 � i NHS�•
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p
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
A pliratiutt for Uiiipw i Wark,i C ontitrurtion 1hrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
. .�a A-f �'o
Ifeor n Addr ss ���r or Lot No
......_ ..._...... -----•--------------- —
Ow er Address
a -21---- .... ---A'x.. Xla --------^ ----------- -----------•---------------
Installer Address �/�
UType of Building q Size Lot....VZ,.0a......Sq. feet
Dwelling— No. of Bedrooms----------- - ---------------------------Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building `��1 "�„„,,� -_- .-._ p ( ) ( )p,, yp g (/t/��-`$-. �'�o. of persons............................ Showers — Cafeteria
Q, Other fixtures ........................................
d ,1 /1
-- ----------------------
W Design Flow-------------------I1.0... ...--gallons per. "' n per day. Total daily flow-------- ........................gallons.
WSeptic Tank—Liquid capacity.1.UUgalIons 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 )
a
Percolation Test Results Performed by..-------------------- ....................... ........................ Date..-. .�-al.". `f
,--I Test 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 /�,, -------------------------------------------------------•---•----------••---.........................................................
Description of Soil-... ---------------------------------------------------------------
x -[�
U .----------•---------------------------•--•------••--------------------•-----------•-------------------••-•-------------•-------------•------------------•------------•------•--•-•--------••-••-----••.
W
------------------------------------------------------------------------------------------------------------------------------------•------•-----------------------------•------------•-----•-----.....
U Nature of Repairs or Alterations—Answer when applicable.-..............................................................................•.-----.----.---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Corn fiance as ern 'sued by the board of health.
Signe " �..Z�--
Dace
Application,Approved BY ( s --�... ............................ .............................------------------- ..... � �.:-.;
Application Disapproved for the following reasons: ... . . ...................................... . . ..............................
------------------------ --- ---- ------------------- ------------------=-------------------- -------------------- ------------------------------------------------------------- ---------- ........................................
Dace
Permit No. ......... .b. .................... Issued ----------,',P--"---- 9 ...............
Due
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Terfifirate of l'��T omplianre
T IS 0 CERTIF , Th t the Indivi�'al Sewage Disposal System constructed (L/) or Repaired ( )
by . ...... ....... ...% �r�.....>wUdit��'
u` - - -
at ..... .. ..._......... ..h................ ..... 1 '1 `------.^.`yL..s�� - -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .,/ j �?.�.�..-----_. dated .._... -------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....._.: '"" - --... Inspe ox.:.. '
No.._ 'J�Q v Fres........ n..n....
-THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphratinn for Di-ripnitti Wjark,6 Tianstrnrtijan ramit
Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal
System at;
G ....._ .. .:................
oca ibt1 Address or Lot No.
Owpier __....___.Address
Iccstaller Address //r
0. �7( Uk-.._..Sq. feet
U Type of.,Building L( Size Lot_______�;._
Dwelling—No. of Bedrooms----.------ ___________________________Expansion Attic ( ) �� Garbage Grinder ( )
aOther—Type of Building [ No. of persons____________________________ Showers ( ) — Cafeteria ( )
aOther fixtures ------------------------------- - - - ---_
—....._._...- ••--•----•----•---••---------••--..........
III � �� :-•-•---.------- ---- -----•--•-----•---- -
t w Design Flow-------------------11_0---------------gallons per-per-son per day. Total daily flow........ ........................gallons.
WSeptic Tank—Liquid capacity.1 UU.gallons Length---------------- Width---------------- Diameter-............... Depth................
I. 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------------- _y. ................... Date....lL�.c��— �1 ------
,� Test Pit No. I...... __ __minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
�Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-- ---------------------------------------------------------•--•-----....•--.........................................................
pxD �escription oo ----- � -------------------------------
/ -
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in-operation until a Certificateof Co p iance has been ssued by the board of health.
j -Z q�
Si ne �� l ,C�L?rlo1./. Da e
�, �.
Application.A )_,n
� -Da� !provDate
Application Disapproved for the following yearonr. ....._............... .... ....._................................. -.........._............ .. ......... .. -
Dace
Permit No. ......... ----- ---------- Issued ...........,3..........1_0------9S77-----------_
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Q.1er#ifirate of Compliance !
T .S IS 0 CE That th Indivi nil Sewage Disposal System constructed (V ) or Repaired ( )
kG >?
bC 1/r
_��
at ....._.. _...._�_��................._:------------ ---- '�`'1 - ...- .. .....
.......
................
_.. -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _�i—..-..���.G-....-------- dated ....-...................................-....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
. '- do.. � � �� �.
DATE..... _................._... Inspe �0
--_---------,_..-----_---_-------_,-,----_ -----•------ ------ ----.
j THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No........
......`.... /�
TOWN OF BARNSTABLE
`J �.�� FEE.....1.n..�:.�.....
Rappq1� tr inn rrntit
I Permission is hereby granted----- UifC ------------------------------------------------------•----------------••---...........--
to Construct f V) or Repair ( _) an In ividual S_ewa e Dis osal System
at No
�y
Street
as shown on the application for Disposal Works Construction 'er it No.��..:��C�Da d-------------------------------------------
,of�'Z0 ��... ............................... Board of Health j
DATE...... ............ __..,- ------- f
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
Town of Barnstable P#_ 13171
Department of Regulatory Services
a�rwernace Public Health Division Date 1 ( 1
MASS
200 Main Street,Hyannis MA 02601
Date Scheduled oZ Time Fee Pd. � 00'
Soil Suitability Assessment for Sewage Disposal
Performed By:PCrc ,--I" LC-_ !EA k-e Witnessed By: °'
LOCATION& GENERAL INFORMATION `
Location Address ' Owner's Name 1 I A
Address63
Assessor's Map/Parcel: ®7C? 06 Z_.. Engineer's Name
NEW CONSTRUCTION ,,n ,, REPAIR i. Telephone# — 7 3`2—q—7
Jk `� , Slopes 'Yo --
Land Use S p ( ) `f Surface Stones
Distances from: Open Water Body ft Possible Wet Area y ft Drinking Water Wetl7�'-S_6 ft
Drainage Way C v ft Property Line eft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands fn proximity to holes)
41
Mls-n cl;) P,2•v t
Parent material(geologic) U} �S Depth to Bedrock /V, 1 a
Depth to Groundwater: Standing Water in Hole: A�I A� Weeping from Pit Face
ti
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in, Depth to soil mottles: in.
Depth to weeping from side.of obs.hole: . —ir., Crr undwater Adjustment - ft.
Index-Well# _ Reading Date: IndexVell'level Adi,factor Adj.Groundwater Level, ,o
PERCOLATION TEST We Thne..��
Observation
Hole# Time at 9"
Depth of Perc Time at 6"
start Pre-soak Time @ Time(V-0)
.,l
�.
End Pre-soak e -
Rate Min/Inch. �-
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-- ------
sa
***If percolation test is to be conducted within 100' of wetland,you must first notify-the.
Barnstable Conservation Division at least one (1) week prior to beginning. Y
Q:\SEPTIC\PERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders.
Consistency, vl
G -!2S !=c.L -
Z"5y V
DEEP OBSERVATION HOLE LOG Hole#�d
Depth from -Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
3 —70 Y L15/`t
711 �-
DEEP OBSERVATION HOLE LOG ' Hole#. -
Depth from Soil Horizon -Soil Texture Soil.Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling_ (Structure,Stones,Boulders.,
- - Consistency.%Gravel)
I
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon 'Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
_ Consisten
. ...e - Flood Insurance Rate Mau:
Above 500 year flood boundary No_ Yes __
Within 500 year boundary No , Yes
Within 100 year flood boundary No Yes `
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? --�
If not,what is the depth of naturally occurring pervious material?
o. Certification. ._
' I certify that on 1 � (date)I Have passed the soil evaluator examination approved by the
I Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required�tra'�i g,expertise and experience described in 310 CMR 15:017.'-
_Signature Date
Q:%SErnc PERCFORM-DOC
Z07
S z
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wi v
L.o 7-
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\AJ T'rt I GRnp�
z � :-� P ve �
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ii :•
TTUP ��Ppe iu� •;l 5�:a � -
u 6 4'pP� . 5�rb
5l�1 �- Z tNv f 'BoX 15(e, SEt'T 1C (C �i
_ GAL... .
A L H IJ a-�-e : �t�. S j�2vcT-U E� TAR
7 A 4a
W/T+-t SCr PAO re-E 1 r�t Q 4-f ° S U'.}..`•',';a N a
WASLIED u� 12 L TL T5 C-
4 42t. ?VC,. SC'kC-D
I•D G.O O C `r� AL Ft�v f
ry FiV-01't L-E O
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► Pam- 2 u5 �
Design Data
Single Family - 4 bedroom
No disposal, Daily Flow = `
4x110=440 GPD. Septic tank =
440xl.5=660 gal. Use 1500 gallon
septic .tank.
i : DisposaL Use 2-6x6 leach pits
w/1' of- stone. Bottoms. = 100 sf @
j 1.0 G/s.f. = 100 G/D.. Sides .= 301. �-• //,�.,
s.f. @ 2.5 G/s.f = 754 G/D.
I certify the proposed dwellingoF M4�
conforms to the sideline and setback '�P� ss�c.
requirements of the Town of Barnstable , � wi CiaM n,/t IL,,L 5 MA
and is- not located in the .floodplain. N Y E yi _
JZ �
No. 19334 �
L � �� FA, Q
Pro a sional .Land Surw yor Date
8axr� f IAJ yE, /lvC-
GLE1i i7GxJ e,45 -a c vQ i o 14AJ o
N s TA>31-� 6, ZT 5, M A-/4e5 i' 0 u