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c Commonwealth of Massachusetts
Title 5 official Inspection Form
(�
yb Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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157 Mocking Birc Lane
Property Address
N.A.Realty
Owner Owner's Name '
information is required for every Marstons Mills MA 02648 06/01/2019
,-:
page. City/Town State Zip Code Date of Inspection =.y
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer, S- j 3X
use only the lab A.Riker `
key to move your Name of Inspector
cursor-do not Riker Land Construction
use the return Company Name
key.
PO Box 726
Co
� Company Address
South Yarmoith MA 02664
City/Town State Zip Code
508-776-6460 S14590
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
06/01/2019
Inspector's Signa:ure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days,of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 r p
IVI/
cx' Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
requiratifnis Marstons Mills MA 02648 06/01/2019
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
On observation of septic tank ,distribution box and inspection port of S.A.S.there was no indication of
system failure .
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required fcr every Marstons Mills MA 02648 06/01/2019
page. City[Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
h Title 5 Official Inspection Form
e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page_ City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 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 CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
Description:
Number of current residents: 2
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
information in this report.) El Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2017= 916 Ply
2018= 72 GPP
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
I
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: n/a
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) j
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Tank original new d-box and SAS installed 03/16/2012
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 1feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Crawl space with PVC pipe with no indication of leakage or past staining
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: .5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5x5x9
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle
38"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle 31-
Distance from bottom of scum to bottom of outlet tee or baffle
7"
How were dimensions determined? Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was observed to be in operating condition with no defects observed
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
IN Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner .Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
—tom 9
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert equal to inverts
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.):
Dbox inspected with stain line at operating level at outlet pipe inverts
i
t5insp;doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
r
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information, is required fo-every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 4 high cap
infiltrators
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
I�
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is Marstons Mills MA 02648 06/01/2019
required for every
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Inspection port observed with no standing water in base of SAS
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
�I
t5insp doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
< Commonwealth of Massachusetts
Title 5 Official Inspection Form
R a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is Marstons Mills MA 02648 06/01/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
f -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >10'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: 03/2012
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Test hole on file from 2012 Installation
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Test hole on file from 2012 installation
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
157 Mocking Bird Lane
Property Address
N.A.Realty
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06/01/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc--ev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
1 V V1'l�l Vl' ITAKt��l f�lf Ll:
LOCATION. .5 �_c�-'_t�'be et) Lgge SEWAGE# d0la? 0:57
VILLAGE ASSESSOR'S MAP&PARCEL 13 .A
INSTALLER'S NAME&PHONE NO,
SEPTIC TANK CAPACITY 0 // f ,sib ZZ k
LEACHING FACILITY:(type) `�"//,' ���,7,��//r.�`� (size) pl, 4,-4 j �%
NO.OF BEDROOMS Q '&d>ceiyS
OWNER 1 feC 1-1— C.
PERMIT HATE: .S�' COMPLIANCE DATE:_ � ) -
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Ir �kk- /O�Feet.
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of.leaching facility) /f/i Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility)
' r Feet
FURNISHED BY ,
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1
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
KAA& P Public Health Division
.e39. �.
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: 2l Zd 12 Sewage Permit#Zo/Z- 10S9 Assessor's MaplParcel Z
Designer: 65 ✓-41^J e'd�tr''Z' Installer: ��k"'1
Address: /Pd. Ax 7/3 Address: Va x 72L
On �!'�� was issued a permit to install a
(date) (installer) /�,^n
septic system at lJ! ��<Kl.�Yfigo LA����'t�'1 based on a design drawn by
(address)� ,iJ�-�f"'L�'�w^''a't'w� dated/Al wgr
/ (designer)
v I certifythat the septic system referenced above was installed ep Y substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system-referenced above was-installed with major-changes (i.e:- f
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State &Local Regulations. Plan revision or w
certified as-built by designer to follow.
. ._ N OF MqS 9cyG .
S
,g TERENCE s�
(Insta er's S Offife) HAYES
No. 979
�'01STe
sgN1 TART
(Designer's Vignaturf (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU
Q:Health/Septic(Designer Certification Form 3-26-04.doc
�TOWN OF BARNSTABLE q
r LOCATION /S Ax k,q ,b.-rJ Lq#e SEWAGE# off®/
VILLAGE 44i51-1.T A'1i- ASSESSOR'S MAP&PARCEL J,3 07
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) II,,,r x/d "
NO.OF BEDROOMS a m �dG9�9S
OWNER ]((CC
PERMIT DATE: -?" Q' Q, COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4/,o kI411C., f0"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
1 FURNISHED BY
i
0 cIC rv� Jr ��
64A
ir..
i
i � Y
J
No. � ��� o�� Fee IV_",
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
21ppYication for Misposal 6pstem Construction i3ermit
Application for a Permit to Construct( ) RepaiUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components .
Location Address or Lot No. P 7 Aloe mybi.,c Lael►Z Owner's Name,Address,and Tel.No. QP !
/j'JarSfm�Sl'�'�S M S�`1, tf'1�i
Assessor's Map/Parcel /3 a�cc l �.r 1��PC j,t `�6 �,/o., � 4n•
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. j 05 S�cftzke�v�
L.C. �.K �a Ire 7a G �P sv- s. 7C�,,, r; ¢
�- T-/4,meAk•M 0946 Sw �✓,�L,tr/,in s as
G`
Type of Building:
Dwelling No.of Bedrooms �E✓® Lot Size A,I�d sq.ft. Garbage Grinder( )
Other Type of Building I��s;r��p ��� No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 330 gpd
Plan Date��ZJA , Number of sheets , Revision Date
Title
Size of Septic Tank M-DD og•/% Type of S.A.S. V Zo
Description of Soil Tr 4*• 1.7G A MC4 d
Nature of Repairs or Alterations(Answer when applicable) E,*1KX> W q S7. f 0 4A;wi' i'ASAW) L..i
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 3joaQ
Application Approved by Date 3
Application Disapproved by Date
for the following reasons
Permit No. � I O Si Date Issued f
PLO 3 �'
� 05
No. O Fee I
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes r
01ppYitadon for Zisposar 6pstent Construction 3permit
Application for a Permit to Construct( ) `Repair4-),`Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 7 Ale,-K,.?bo's ad p- Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel /3 I<-r PC
Installer's Name,Address,and Tel.No. S'o€ 9�G•6YGo Designer's Name,Address,and Tel.No. 4-; SthxKc r�
L.C. �'�'�i Y �d G rt fSri C.S•?<i.A�o�+ti. N9 oaGG4 $W �✓�y�rncr.�n! 5�,�3'Y�S (i1G6
Type of Building:
Dwelling No.of Bedrooms J L✓O Lot'Size ?0, q.ft. Garbage Grinder( )
Other Type of Building /PPS,corn 7 i'G No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 330 gpd
Plan Date 0.' G-71.G a Number of sheets / Revision Date
Title
Size of Septic Tank hod e'1/4_ Type of S.A.S. C� yam' T{�i�✓q 4r b'/G
Description of Soil X. p- 47O CIOg.ci'P 4'Q 94
Nature of Repairs or Alterations(Answer when applicable) EA'/.3'Ak
fad T,n F/�.•�fo,�' y, �S �or7 e ,�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in J
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed - Date 3 3 ac3�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. o Q Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired%, ,,j Upgraded( )
Abandoned( )by /�! L.C,
at I s17 l�'1cc/ti'r i+y,Ej,yoA wn e has been constructed in accordance
a0 r 6s� 3 _ 3 �
with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated
Installer �,'�e,► Designer ✓`lv ee 4 S"c✓ ,^e+t i ►+
#bedrooms T"k/O Approved design flow �L` 0 and
The issuance of this permit sh 1 not a construed as a guarantee that the system will nctio �ign \
Date �j 6 � Inspector /-- - ----.�--
No. ��I 5 M k. ,,., a i �" :; oS Fee`
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
- � �~ isosaips'tCIIY Construction Permit
Permission is herebyranted tot,,,j sfruct Re air Upgrade
g ( ,) P .jr-) pg
System located at 114C 6,;p L a„C 14A w Awog ^-gr
17*>17\1
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special oonditions�
Provided:Construction must be completed within three years of the date of this permit
Date
Approved by c• +..
iY r • "- ,,vim 1 .
Town of Barnstable P#
Department of Regulatory Services
Public Health Division Date
200 Main Street,.Hyannis MA 02601
aytt
Date Scheduled Time / Fee Pd.
Soil Suitability Assessment for Sew Disposal
Performed By: 6`" /c Cc Witnessed By:
Y.00ATIOI�T 8r GENERt�I.r_INFpR11�IAT'IHN ./r ' j
Location Address e �J �PC 11�!7I eel AC{h Owner'slName'�LJ o y' Git�
pa/!,�4,0 /�/�ls Address/ �Q Cc� LLC
Assessor's Ma /Pazcel: �'3/�A7.�, Engineer's CI���I�fr�I2y p gm Sft1�E'TSt� L�/UEi,�ti�A 1�6
NEW CONSTRUCTION REPAIR Telephone# 5a SSS_6 f 0&
Land Use �� '7�- Slopes(%) G Z' Surface Stones
Distances from: Open Water Body ft Possible Wet Area 7�ft Drinking Water Well >-Zez-)ft
Drainage Way NO ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Mdc ,-iAJ6,"g,fk-b / ,Ak1
Lot 9&
.^i
tMM�
r'kp" Q
Parent material(geologic) Depth to Bedrock 0 ---!
Depth to Groundwater. Standing Water in Hole: N/ Weeping from Pit Facer—
I `..l
Estimated Seasonal High Groundwater 7 2y
DETE ATION FOLt SASQNAL 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: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
PE TEST nttte 3 . rlme l' V
Observation /
Hole# t Time at 9"
Depth of Perc 7Z— Time at 6"
Start Pre-soak Time @ Time(9"-6'�
3 End Pre-soak C
. 1 Rate Min./Inch
d
S . /
Site Suitability Assessment: Site Passed (/ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back--------
***If percolation test is to be conducted within 100' of and,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
"s Q:\SEPTIC\PERCFORM.DOC
i
MEP'OBSERVAT'IUN HOLE LOG`. Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consisten %Gravel
L
�s-ram C C 5,
DEEP O3SRVA3'YON' E LOG' Hole# Z�
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consis " I
'DEEP OBSERVATION HOLE LO;G
Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) ______(USDA)_(Munsell)—_ Mottling -(Structure,Stones,Boulders.
Consistency %Gravel)
OBSERVA�O ��
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
3
Flood Insurance Rate Man: / r
Above 500 year flood boundary No Yes l/
Within 500 year boundary No of Yes
Within 100 year flood boundary No 6� Yes - -
f
Death of Naturally Occurrine 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? 'y
If not,what is the depth of..naturally occurring pervious material?
Certification / /
I certify that on / (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and.th a above analysis was performed by me consistent with
the required tra g,a and'exp 'e a cribe 10 CMR 15.017. I CC,V Se �'S
S Lit Date /�...
Signature _41—za
! Q.\SEPTIC\PERCFORM.DOC
SIKE Town of Barnstable Barnstable
of
°- Regulatory Services. Department is"aC p
l'+ BARNSrABLE.1 r. m
19M^I.S.
a, 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 # 7006 0810 0000 3524 5560
December 14, 2011
Mr.& Mrs.Bruce.Berrian
3815 SW Temple
Salt Lake City, UT 84115
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 157 Mockingbird Lane,Marstons Mills, MA was last
inspected on 11/21/2011, by Sean M. Jones, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails"under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Over loaded SAS.
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 with the deadline period will result in future
enforcement action. j
PER ORDER OF HE BOARD OF HEALTH
as McKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\Town of Barnstable.doc
r
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=383
N
1' � �+3ex oM+.arss�r.ipilw
Logged In As: Parcel Detail Monday, December 12 2011
Parcei Lookup
Parcellnfo
Parcel ID 013-025 I Developer LOT 95
Location 157 MOCKINGBIRD LANE I Pri Frontage 125
Sec Road I Sec
Frontage
village MARSTONS MILLS I Fire District C-O-MM
Town sewer exists at this address No ( Road Index 1034
Interactive -
Map ' I
Owner Info
owner BERRIAN, BRUCE D& REITA M I Co-owner %DLJ MORTGAGE CAPITAL, LLC
Streets 3815 SW TEMPLE ( Street2
City SALT LAKE CITY I State UT. Zip 84115 Country
Land Info
Acres 0.46 use Single Fam MDL-01 I Zoning RF Nghbd 0105
Topography Level I Road Paved
utilities Public Water,Gas,Septic I Location
Construction Info
Building I of 1
Year 1982 I Roof Gable/Hip I Ext Wood Shingle
Built Struct Wall
Living 957 I Roof Asph/F GIs/Cmp I AC None
Area Cover Type
29.
Style Ranch Wall Drywant ll Rooms Bed
2 Bedrooms
Int Bath Model Residential I Floor Carpet Rooms 1 Full + 1 H I Bas 3
4
Total
Grade Average I Type Elec Baseboard I Rooms 4 Rooms
22'
Stories 1 Story Fuel Heat Electric Found I ation Conc. Slab 14
Gross 957
Area
Permit History
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=383 12/12/2011
S,��--5
� �
��
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/21/2011
page. City(rown 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: I ' .� ZE
key to move your e
cursor-do not Sean M. Jones
use the return
ke . Name of Inspector < 9
Y
Capewide Enterprises
� Company Name _
153 Commercial St.
Company Address
Mashpee Ma. 02649
City/Town State Zip Code
508477-8877 SI 4522
Telephone Number License Number
B. Certification
I certify that l 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 16.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
11/21/2011
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use:-
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11110 Title 5 Official Inspection Foam:Subsurfa ewage Disposal System•Page 1 of 17
f
a
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
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
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
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
❑ ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is Marstons Mills Ma 02648 11/21/2011
required for
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ 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 gpd
t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
157 Mockingbird Lane
M
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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
W Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i,
�^M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system 1982
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gallons
Sludge depth:
t5ins•I VIC 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
157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
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
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
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.):
Septic tank was located but not opened
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments on pumping recommendations inlet and outlet tee or baffle condition structural integrity,
( p p 9 9 Y,
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•I m0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
info required for information is Marstons Mills Ma 02648 11/21/2011
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.):
At time of inspection the leach pit had approx 5' of standing water with heavy scum buildup above the
inlet invert up into the riser indicating that the pit has been hydraulically overloaded resulting in a
failing septic 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/21/2011
page. City/Town 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
I
' I
t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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)
s
❑ 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:
Groundwater elevation was not established
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 157 Mockingbird Lane
Property Address
Bernie Laverty
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/21/2011
every page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
LOCATION s, EWAGE PERRIIT 140•
VILLAGE
M-A 2.SMAJ n-7/!1S
INSTA LLER'S NAME A AD ORE S.S
F x c 1sVR�jIA-1
u/Ai i
tU I L D E R OR OWNER
2Q®
DAT- E PERMIT ISSUED C130IP
DATE COMPLIAN-CE ISSUED
i
16. 1
I ;
I �►�tr� �-t Nv
No...0 1-Z'.4 Fps. _1E ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ .........OF.'...... ,..1.�. :! :'`.71 P�+�.... .....-----...........................
Application is hereby made for a Permit to Construct (ram'or Repair ( ) an Individual ispS ;:
�s
System at: ; RO!?ERI c
�O�l�If1/C�/ i/L / `� c
................_.......�. ................... .... t�y ..... - . .............................................� �ORBS�� ram"
Location-Address or Lot No. iti. " t
/ O_rr.:�S .....1 1 . '!?�' :t ---------------------`\" �..i..
/ Owner Address
a Installer Address ` L
Type of Building Size Lot_. '. ` .......:. eet
U Dwelling—No. of Bedrooms..............Z.......................... Attic ( ) Garbage Grinder (0)
Other—Type T e of Building No. of ersons__.....
a YP g ••�--•---•-=•---------- P V................ Showers ( ) — Cafeteria ( )
Otherfixtures ...................................................... ----•-•--------- ------- -----•--....
W Design Flow.................................... "._gallons per person per day. Total daily.flow____--_•-__- .t-_«.........--......gallons.
e —
WSeptic Tank—Liquid capacrty,/t?��'...gallons Length.......8 _..___. Width....: .......... Diameter........:_._.... Depth....
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No........1_........... Diameter....JO.......... Depth below inlet......Y---._...._ Total leaching area.._?�`i......sq. ft,
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed :................ Date...:ter". .- . =......•......_..
Test Pit No. 1....<Z..minutes per inch Depth of Test Pit.... <.. ._..... Depth to,ground water._J'&r�K�7 ...__.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit............._...... Depth to ground water......................Z.
.................-----.......--.................................................................-------------------------------------------------
O Description of Soil....d. el-0 PA. 5�.t� *2_!�_..----•Z/.-� ...�¢��� ��i=l��......°�L��fcjr�i--3AAP.......
x
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 Sanitar Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h/' ' ued by the boar f health.
Si ne .... .. . .... .....................•----........_.Application Approved By...... �i/J` .---•---- <. � ....._..
Date
Application Disapproved for the following reasons------------------------•--....-------------------------------•------------------•----------•--•-•--------......_
.........................................................................................................--....._....----------------------------------------------------•----••-------•-•-----••-_-_---
Date
PermitNo........................................................ Issued-.......................................................
Date
ND................. Fss.....,�S...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH j
...................Ns'..r.4.I........OF........ `.rJ / 1�°'?>1...C"'
Appliration for 31ispniia1 Works Toustrurtinn
Application is hereby made for a Permit to Construct (L--y or Repair ( ) an Individual m i (saV.
System at• r ROBER I y "
, fief }.'} GORDON
................ _._. .... ..... .............. ..................:... ....
Location-Address or Lot No. f Y 5
t+p,f� { A)All tc :? ��.`d !.l.................. .......... � uo.17493
Owner Address
Installer Address
Q Type of Building Size Lot_ ________........... feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building -- `¢:::'_: _ . p ( ) ( )
...__._= No. of persons :................... Showers — Cafeteria
a' Other fixtures -----•----------••------•-•••-•-
W Design Flow.................................. . ....gallons per person per day. Total daily flow................ _.c .................gallons.
WSeptic Tank—Liquid capacity.,"..,";.,.-,....gallons , Length...... .... Width---:?_........... Diameter-----n^:n..... Depth.._2,k✓._.....
x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No._.......!----------- Diameter....t�.......... Depth below inlet.......%......... Total leaching area_:.''_Z._..._sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`" Percolation Test Results Performed by.=?r`t'_"!�:t Z-- /'�r-—, I �,`��`' �-
a Date '...... -- -----..
Test Pit No. 1._ _: ..___.minutes per-inch Depth of Test Pit.....:.. ........ Depth to ground water..:.-
..............Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O '.... ! P 1 r iJ
Description of Soil.... .......................'' '. ' ...__.............._..
U ---.._...•••-•----•-......•••--••-•••••••..............•-••--•---..._..............-----.....--•--•••-•--••-------•-•-•••••......------
----•------------------------------------------------------------------------------------------------------------------------------••-------•---------------------......._.............--••••-•••••.....
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
----------------------------------------------------•---....------------•-----------.•............... ------•----1---------------------------------------------------•-•.. .................•---......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar Hof health.
r -
g _..�. . '`> ._.....•-•..._.....•-•-- �
����--•-- ate
Application Approved BY --------------•-••-...::... .............. -'!''t k..` `----.....---
Date
Application Disapproved for the following reasons:..............................................................................................................
--------------•-----.....----------...........------•---........•........--------.....---•--•-------•-•-•. ................-•-•----------..............................................................
Date
PermitNo......................................................... Issued•.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................................................................................
Tntifiratp of Toutpliatta
THIS lS TO CY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..... �?. ...........................7....••.. ---•-•......•--.._...-•-•• •••--- --._.....••-•-•-•••••----•..........................
ee� InValler wv
at------------------ < ....... A 'r -------------------------•------•--••----------------
has been installed in accordance with the provisions.of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit`No.-- .. ._ ._ ..... dated............................. --------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION,SATISFACTORY.
DATE........................................... M..................:... Inspector....---.......R: A ...----•-......---.........--•••......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NQn .. 4 .. OF.....................--------..........................-----.....------.............. FEE. . ..o ••..
�i���a�tt1 �rk� �utt��rttr�i�tn rrmi�
Permission •is hereby granted.......... !------1� .......-•--.---••••-•••---------------------------•--------•--•----...............................•••.•••--
to Constru or epafr �an Sewage Disposal System
atNo..........t........ZAN).. ...... . ..... .. ....
Street
as shown on the application for Disposal Works Construction Permit No...... ............. Dated..........................................
----------------------- :-.. ..:_ ••_...
p of Health
DATE........................ .............................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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SOIL LOG MOTES
I. SEWAGE FLOW = 2 Zo
2. LEACHING AREA -f - yd6
-SOC •o iz- =- p: 3. SEPTIC TANK = ;Cl6 6:dx //•!
el 4 ALL WORK MUST COMPLY WITH MASS.ENVIRONMENTAL
CODE-TITLE 5 AND TOWN BOARD OF HEALTH
REGULATIONS.
C:✓./' 5. BRICK TANK, DIST. BOX & PIT COVERS TO WITHIN 12"
OF GRADE
70,= 6. THERE ARE NO WELLS WITHIN 100' OF THIS PIT.
T. T Tftl•M•-I0,4`-lDF-•THfS
41,
(� 5 rIJ.
PERC RATE = < Z M=r�f�/rcJ c� Fs�`!p'NAi.E
DATE: 6w.
--9G FINISH
1 GRADE
lip
�IVF
t° `�� C. PIPE kkf c> / ✓Cr k1 2„_1/8,_I/2"WASHEO
� 2 3 PIPE 2vGPIPEPITCH I/4T.MIN. •' PEASTONE
PITCH 1/8/FT. MIN.
- PITCH 1/8'%FT.MIN.
'A., I 3/4"-1 1/2"WASHED
9$ 17 .' %3.vo -
9a,cv STONE FREE OF
�o Cl TEE DUST. BOX
*° FINES,DUST,IRON
* NO.OUTLETS= 3
6'DIAM. PRECAST
FOUNDATION SEPTIC TANK 66,0 —uu I L�__
OR BLOCK PIT
LENGTH = r
WIDTH = J' LEACHING PIT
SEWERAGE SYSTEM PROFILE
(NOT TO SCALE) WATER TABLE
HARRISON SCALE /� ' PLOT ��A� WITH SEWERAGE AT
ENGINEERING DATE , SYSTEM
FLINT LOCKE DRIVE
PLYMOUTH,NIASS. 0 23 60 PROJ, _ FOR
•
. _
8C8YC SOIL TEST
TOP OF FOUNDATION 20 FT. .MINIMUM FROM CELLAR OR CRAWL SPACE
DATE MARCH 7..201 a
:OF SOIL TEST M0
A2._
' ELEV. 100.00_ 10 FT. MINIMUM
10 FT. MINIMUM FROM SLAB . SO4L TEST DONE BY TS R IN RING :1
CLEAN SAND
WITNESS
ED 6Y ..Q D-' E5
8
(ASSUMED)
CONCRETE INSPECTION PORT,
COVERS I
:
-�7 HOLE '
4 SCHEDULE 40 PVC .PIPE LOAM AND SEED OBSERVA !ION HOLE 1 'ELEV:. 99.0
2" LAYER OF.
MIN. PITCH 1/8" PER FT. 82
1/8 TO 1/2 PERCOLATION RATE _."< 2__ .MIN./INCH AT INCHES
WASHED STONE
DEPTH HORIZ TEXTURE COLOR MOTT. OTHER {
4" CAST IRON 'PIPE » 99.4 MAX., OR FILTER FABRIC VENT
�t 97.15 MIN. : NOT REQUIRED 0-3" Ap LOAMY SAND 10YR4/1 NO
(OR EQUAL) MINIMUM :
PITCH 1/4 PER FT. Z 3-23" B LOAMY SAND 1OYR6f6
FLOW TEE " 0YR7 2 J
LEVELERS 23 55 Cl SILT LOAM 1 f
FLOW LINE w 55-120" C2 COARSE SAND 2.5Y7/4^
96.40all
ELEV, 97 _ 10" NO WATER ENCOUNTERED AT " ELEV. _ ,r89.0
MIN. » o 0
ELEV.
10
2 " •
LEVEL o �_ J _€bc _ 95.07'
120 `
ELEV. _ � �'� ADD AS 07 s" SUMP ELEV. _ _95.Si0 _
'ELEV _ OBSERVATION HOLE 2 E� ;�8.9
EL€V. � _
_
•
BAFFLE Tp Tt
DIS 11�IBU I ION DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
ELEV.
LIQUID OUTLET' 4 HIGH CAPACITY INFILTRATORS WITH 0-3" _Ap LOAMY SAND 10YR4/1 NO
BOX STONE IN AN
DEPTH E
(EXISTING) ��.$S1_ Z 3-23" B LOAMY SAND 10YR6/6
4 FEET 14 INCHES TO BE WATER TESTED � 7 .17 -
5 FEET 19 INCHES 1M GA, t ON IF. MORE THAN ONE OUTLET 11 X 36 X 10' TRENCH FORMATION _ 23-55" Cl SILT LOAM 10YR7.f2
6 FEET 24 INCHES Vv0 GALLON
7 FEET 29 INCHES (TO BE PLACED ON FIRM. BASE) SOIL ABSORPTION WELL N A 55-120 C2 COARSE SAND 2.5Y7/4
8 FEET 34 INCHES SEPTIC TANK ZONE
3/4" TO 1 1/2" CLEAN INDEX NO WATER ENCOUNTERED AT 120" ELEV.,.- _
SYSTEM (SAS) 88.9- -
DOUBLE WASHED STONE ADJUST
FREE .OF FINES & SILT
DESIGN CALCULATIONS
SEWAGE DISPOSAL SYSTEM PROFILE US S PROBABLE WATER TABU ELEV. ¢ ���__-
NUMBER OF BEDROOMS 2
GARBAGE'DISPOSAL UNIT
OBSERVED WATER TABLE ( j j ) ELEV. = TOTAL ESTIMATED FLOW
NOT TO SCALE _ BOTTOM OF TEST HOLE ELEV. '- 88 9�,
( 110 GAL/bR./IDAY. X -2.... OR.) -2XL GAL/DAY
_ REQUIRED SEPTIC TANK CAPACITY _'�--GAL. `
ACTUAL SIZE OF SEPTIC TANK (EXISTING) _ W GAL..
SOIL CLASSIFICATION w.._.l._..
: DESIGN PERCOLATION RATE <A i MIN.AN.
EFFLUENT LOADING RATE. . GAL./DAY/S.F..
�j LEACHING AREA SQ..FT.
LANE
__,.-- 99.1 � {19X36�(47X2X10/`1� ` I
G
IR '.
99.0
I LEACHING
x 0.74(AR
/`��� LE EA X.RATE) ..�E"1,.�Q GAL AL/DAY
V 8.4 x 99.5
'♦ RESERVE LEACHING CAPACITYQI _;GAL./DAY
157 ,
■ 99.8
_ ,.:NOTES: , .. .
*-� 7 1. ALL WORKMANSHIP AND,MATERIALS _SHALL CONFORM TO D:E.P.
93<D5
w TITLE 5 AND :TI IE'TOWN'S RULES AND'REGULATIONS FOR
97.9
_
- THE SUBSURFACE DISPOSAL OF SEWAGE.
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
L 2.33
1. WITHIN 6" OF FINISHED GRADE.
- 1 ALL COMPONENTS OF THE SANITARY' SYSTEM SHALL:BE CAPABLE OF
WI rHSTANDING H--t 0 LOADING UNLESS.THEY, ARE'UNDER OR'WITHIN97.0 I
10 FT, OF DRIVES OR PARKING AREAS.:H 20 LOADING SHAM BE
97.1 - USED UNDER OR WITHIN 10 FT. OF DRIVES OR'..PARKING AREAS.
O / 4. ANY MA NARY NITS USED BRING_COVERS TO_�RAOE .SNALt:,._
9
8 l SO U _JO_
_._• EE TARED IN PLACE:
. _ -_ ---- MOR
--- - T- -- -- t •/ - - ---- - COMPLIANCE WITH'
� S. NO DETERMINATION HAS :BEEN MADE TO C . .
' ¢ / DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO,
• 99.3 _
. OBTAIN SUCH DETERMINATION FROM .APPROPRIATE AUTHORITY:
EXCAVATION CONTRACTOR
6. UTILITIES SHOWN,ARE APPROXIMATE ONLY, - '
1 » " A 72 'HOURS
x s5.5
98.7 - , IS TO CALL "DIG-SAFE" AT 1 , 888 344 7233 AT LEAST
■ 97.0" � PRIOR TO COMMENCING WORK 'ON*StTE. ;
J 7. CONTRACTOR IS TO VERIFY GRADES .AND ELEVATIONS AS WELL'AS
f
t
SITE;CONDITIONS PRIOR TO :COMMENCING WORK ON SITE, ANY VARIATION
96
.4 . NG IS TO BE BROUGHT TO THE ATTENTION,OF THE DESIGN ENGINEER _
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"IMMEDIATELY.,
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13• :: - 9. LOT IS SHOWN ON ASSESSORS MAP._--'-____ AS PARCEL25--
OMIT OF 5 - ? �SNor .q 10. ALL UNSUITABLE MATERIAL SHALL BE ;REMQVED FROM UNDER AND
98.7 ._ ss FOR 'A MINIMUM OF 5' AROUND `SOIL ABSORPTION SYSTEM AND BE
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SOIL /
/ J >f4� ? TEE s REPLACED'WITH MATERIAL AS SPECIFIED IN 310 CMR 15.255:(3).
gH rn -° RO :U y "i- o� 11. THE.IN'STALLER IS TO GIVE THE_ENGINEER A MINIMUM :OF"48 HOURS
N� TEST 1y c,;;o `r,:: .• ; \ ..y c� N (NUMBER BELOW
y \ � ., ,. ,. H ES (2 WORKING :DAYS) ,NOTICE FOR THE FINAL]INSPECTION ( U )
SOIL a, 9 o EBACKFILLED OR REMOVED.
l 97 12. EXISTING LEACH PIT IS TO BE. PUMPED AND
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