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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t
�n
u
26 New London Ave
Property Address
Christopher& Marcela Gonyer = ;
Owner Owner's Name
information is Marstons Mills MA 02648 02/17/2021
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 61* 151wo
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
N
use the return
key. Company Name
52 Rivers End Road
rQ Company Address
Teaticket Ma. 02536
City/Town State Zip Code
508-280-3356 S13938
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
02/18/2021
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
v
Property Address
Christopher&Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. Citylrown 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:
® 1 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:
This 3 bedroom home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding (2) 500 gallon
leaching chambers with stone. At the time of the inspection no visible failure criteria was found.
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
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 f f feet o 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
Y P
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 New London Ave
L�
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
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
El ® 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
c Commonwealth of Massachusetts
A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 26 New London Ave
v—
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. CitylTown 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
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
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): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus
GPD
Description:
Number of current residents: 0
Does residence have a
grinder? ❑ Yes No
garbage
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): town water
Detail:
In 2020-55,000 gallons were used and in 2019- 56,000 gallons were used
Sump pump? ❑ Yes ® No
Last date of occupancy: Jan 2021
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owners Name
information is required for every Marstons Mills MA 02648 02/17/2021
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
I
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date .
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
2002
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 32"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
c� Commonwealth of Massachusetts
+� p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 24"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:
H-10 1500 gallon
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
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.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/n
�. � 26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is Marstons Mills MA . 02648 02/17/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
i
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
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: (2) 500 gal
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
r
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. CitylTown 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.):
At the time of the inspection no visible failure criteria was found.
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. Cityrrown 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
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t5insp.doc-rev.7126r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
V � 26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
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: 14 plus feetfeet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 New London Ave
Property Address
Christopher& Marcela Gonyer
Owner Owner's Name
information is required for every Marstons Mills MA 02648 02/17/2021
page. CityrFown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
§ 360-28 Restrictions. Page 1 of 1
Chapter 360: ON-SITE SEWAGE DISPOSAL SYSTEMS
Article XI: Protection. of Areas Served by Private. Wells
[Adopted 8-24-i999,effective 9-2-1999 (Section i3.00 of Part Vlll of the i9.9i Codification as updated through 6-1-1996)]
§ 360-27 Purpose.
The purpose of this article is to protect groundwater from contamination,prevent the spread of disease and protect long-
term potability of'drinking water in areas served by private wells.
§.360-28 R6-strictions.
QA. No -site sewage system serving new construction in areas where the use of both on-site systems and drinking wate
erve or are proposed to serve the facility or facilities on abutting parcels shall be designed-to receive or shall
e more than 44o gallons of design flow per acre per day from residential or commercial uses=systems
CMR 15.216(aggregate flows) or 15.2i7(enhanced nitrogen removal).
itiorr, a-oTT-site-sewage-syste-m--serving-new-cons e the user of b I -en
drinking water wells serve or are proposed to serve the facility or facilities on abutting parcels shall be designed to accept
or shall accept a total sewage design flow of more than 2,000 gallons per day unless provided with a recirculating sand
filter or equivalent alternative technology approved by DEP in accordance with 3i0 CMR i5.28o to 15.289.
§ 3 60-29 Definitions.
For purposes of this regulation,the definition-of new construction shall be the same as that defined in 3i0 CMR i5.002 and the
design flow for a system shall be determined.according to 3i0 CMR i5.203.
§360-30 Variances:
Variances may be granted when in the opinion of the Board.of Health:
A. The person requesting a variance has demonstrated that enforcement of the regulation would be manifestly unjust,
considering all of the relevant facts and circumstances of the individual case;and
B. The person requesting a variance has demonstrated that a level of environmental protection,.that is at least equivalent to
that provided by this regulation,can be achieved without strict application of this regulation from which a variance is
sought.
http://`ecode360.com/6561760?highlight=wells 11/17/2014
2G, kevj LonC/on gTOWN OF BARNSTA.BLE t�
P
LOCATION I SEWAGE # �--3fZ-
VILLAGE ST-OyV 1 4 k ASSESSOR'S MAP & LOT f o 3
INSTALLER'S NAME&PHONE NO. GEV. -1— 4Gat 0 A-
SEPTIC TANK CAPACITY 1�i00
LEACHING FACILITY: (type) 2- IN c Fo &6u (size)
NO.OF BEDROOMS 2
BUILDER OR OWNER F,ech T t
PERMITDATE: COMPLIANCE DATE: o / U
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
q ° 52. 3,
r
No' ?00,2 THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
TO W W — OF BAXL> `QA•B Z ,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct K Repair ( ) Upgrade ( ) Abandon ( ) -X Complete System ❑Individual Components
'2r UAW LO Otts
Location � .e ,� Owner's Name
i Map/`P cel# \ Address
t
Lot# "'r��f'GL.�etr��►L� SeVphone#
RV J
Installer's Na e Designer's Name
rt)-�7 c SNP 3d� OLD Rl mox) " .r. gcLR A-3
Telephone# _ TelephonS#
Type of Building: Lot Size 44 Sq.feet
Dwelling—No.of Bedrooms 2, Garbage Grinder ()40
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures .-rn -
Tv
Design Flow(min.required) Z2D gpd Calculated design flow 33 gpd Design flow provided gpd
Plan: Date 42 -27 .0 Z Number of sheets 1 Revision Date
Title PLjk ) A& 7MIZ.. DS516" OF-^ FRee1Sen
Description of Soil(s) 51rr-V`r1C, "PUIVOSArL s liS"mr^
Soil Evaluator Form No. Name of Soil EvaluatorR. 4JJ;0 1oS N Date of Evaluation 6 -27 -6Z
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /2
c
Inspections 4IN- 0
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM S/96
,.-.-•-, w.i.+.-nY.r.'S..+'.w•„w,.y.-.y--gym _ _ � ..,. .-.. ,-. -
�" .- . ., t"'Ya•-.:.a'•+.,.�y?/"' __...+!y,,..s',_�'�Y"..,,.^,ft..--^�+'ti-•-.- 'r:-e-r.. r hr+^ .. x^x ��
'+' OMMONWEALTH OF MASSACHUSETTS FEE
` BOARD OF' HEALTH
TOW L..) 0F,. Bb,i�1JSTV;)-16L
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applicati6n for arPermit t+o Construct 9� Repair ( ) Upgrade ( ) Abandon ( ) -X Complete System ❑Individual Components
Location Owner's Name
d Map/Pa cel# Address s
Lot# Telephone#
� - Q,Q Installer's Na a "Designer's Name
y yi ')�11C l� 3d(fl OLD FI_NMOU R7.se)uz A,J E!
Address Address
Telephone# Telephon #
Type of Building: Lot Size 20 gv! Sq.feet
Dwelling—No.of Bedrooms 2.. 'Garbage Grinder ( �
Other—Type of Bujld�Dg a' .No.of persons Showers ( ),:Cafeteria ( )
Other fixtures
I �
Design Flow(min.'required) Z`LD. gpd Calculated design,flow,370 gpd Design flow provided. S gpd
Plan: Date CA ' V1 'd Z Number of sheets �_- Revision Date
TitlePL,btkS O ' ,A `i�R�$ •SG�. ` ��1 �
r
Description of Soil(s) rJ' r W r1 C V)S 10SA'-t� �J' 4$'�.►�
Soil Evaluator Form No'` Name of,Soil Evaluator) . LML " Date of Evaluation rc •2.7 t'S2
DESCRIPTION OF REPAIRS OR ALTERATIONS
t
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions:of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ a Date
Inspections l S �N- _ eA60
1 4
t
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 `
No. aUod- 3S.z THE CO)MlM--ONWEALTH OF MASSACHUSETTS FEE Gv
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System 1 #)
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( )
by:
at 24 jije&-✓
has been installed in accordance with the provisions of 31 1 C R 15.00 (Title 5) and the approved design-.plans/as-built
plans relating to application No. GQ;?' dated V 0 Approved Design Flow (gpd)
Installer
Designer: Inspector v Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96- f
,f
No. OA&- 3=0 THE COMMONWEALTH OF MASSACHUSETTS - FEE 160
—
Rcr�z �/�D BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct G4 Repair,( ) Upgrade ( ) Abandon ( ) an individual sewage
/�,) r
disposal system at Jt( 1 ►o i../ L o-z#,A M-M J/1 as described
in the application for Disposal System Construction Permit No. aU0.2" 2 dated e116,
Provided: Construction shall be completed within three years of the date of this permit.All I Kcal conditions must be met.
Date �z Bo -rd of Health
' FORM 2 - DSCP DEP APPROVED FORM 5/96 hGWtodt✓^�. /
TM
FORM 1255 (REV 5/96) H&W HOBBS&WARREN PUBLISHERS- BOST N
f
.i
�:rcr2�c. wA 2 '(,3 x 6v LANDra�-
3 (P�Y��w►� � ` l
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UR
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ovT 2-S p�dk_. FoAfi
26 1yew Lon 67an gTOWN OF BARNSTABLE r G
LOCATION 1 SEWAGE # �—_- -Z
VILLAGE 5T_,vV ASSESSOR'S MAP & LOT JD 3
INSTALLER'S NAME&PHONE NO. R,-,'S- GEV-TL!CQQ A
SEPTIC TANK CAPACITY 1-00 9 A
LEACHING FACILITY: (type). 2' S s At (size)
A
NO.OF BEDROOMS 2
BUILDER OR OWNER ode r
PERMITDATE: d a COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
' fie,✓y
I
• I AA
ry /
3�
a
• 2� 0�1 c '�'' 2o e.
3' i�FS
4 - 5-2, 3x
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a
48'-O"
AND. 2i-2 i
AND.2432 AND.24B2 AND.!2446 i WL4
N
2'-4° T-b' 8'-b• '
j 171-01 AND. 6a.
BATH
$EDRDOM 2.4CLOSET
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2A PIASTER b
00
E3EDROOM
r
WALL
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ni
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——————————————
i I WALK-IN 2A .
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LINE OF CEILING CUP ABOVE 4-e $ KNEE WALL al
I OPEN TO O CLOSET
4' KNEE WALL
FLOATING DdRMM — ----- -- _
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w Z �
5'-O' '- . 4-0 I b'-0• i2'-II° T
W-2° Iz EL
d o 14'-0'
48'-O" Z
Q
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SECOND FLOOD FLAN Ef;7T
? A4
JOB: 0242
DRAWN BY. KW
DATE: 7/18/02
E
-
I1'-2° W-2'
o
DECK
BIXX DEAD
AND. 2432 ANDI 2492
I9LiDER I S,1(,.
uTE, Lq
(call 3
j I�ITGNEN oo �u
23'-2°
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3'-4q
o AND.2 b16-2lu
aA
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M7 �I
(s)4 I/4' LVL'e ABOVE FLU9N DIN If M RA
ni 4'-0'
CONCFZM SLAB
PITC44 To DCIOR I
I tI I �•' �
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I I
O (VAULTED GEIUN6)
FAM LY
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AND. 2446 , v'
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4'-00 S'-Id I 7-2' -I
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DRRWN BY= KW
DATE: 7/I6
/
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i
' pi o'r`�•: I N 9'rA-L-•� ��S f�A Fes!-�
GENERAL NOTES.' ,-rev '� �"~sr `' �� ��-�- -r '�"� SOIL TEST PIT DATA
1. THIS PLAN IS FOR THE DESIGN AND INVERT ELEVA TIONS.' G P• . % •0� T.P. -2 8 5•�
CONSTRUCTION OF THE SEWAGE DISPOSAL RND. LEV . }� GRND. ELE6, ,
FACILITY ONL Y. INVERT AT BUILDING $���5 G.l✓. E . G. w. ELEV. _
2. ALL CONSTRUCTION METHODS MATERIALS AND INVERT IN AT SEPTIC TANK 7 0,,
MAINTENANCE FOR THE SS07IC SYSTEM SHALL F}(1 ACCESS COVERS MUST BE XI THIN 6 ' OF FINISH GRADE.
CONFORM TO MASS, D.E.0.E. TITLE 5 AND LOCAL INVERT OUT AT SEPTIC TANK g3, ����c r4 ve
BOARO OF HEAL TH RE60LA TIONS. INVERT IN AT DIST. BOX 92• ;,�• Ov(M; , 5.f� PERO.0 TEST
INVERT OUT AT DIST. BOX aZ' $ � Z' gL
3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO ,5 0 "'��? 8 2•"K7 MIN. $�"•OF
ERT IN T S.A.S r
V HA S ETC. INN .,..
aYEHICLE LOADING (I.E. UNDER DRI E Y , I � _ p J/B .!/2 DIA.
SHALL BE DESIGNED TO MITNSTAND H-20 LOADING. BOTTOM OF S._A.S. ��0' 8 y c MIN. ' , h'ASHED STOi�'E INDICATES 5 fLF•. LO $ 1k
4. ALL SEMER PIPE SHALL BE SCHEDULE 40 OR OBSERVED 6ROUM?M 'A - LIQUID I
0
,--,. .., DEPTH DIST.83. D � � GROUNDf✓ TER
APPROVED EOUAL. AD✓USTED GR0bW VA TEA f 0 N W 3/4 -! 1/2 DIA. v_ t
5. BEFORE STARTING CONSTRUCTION CALL DIG SAFE (ry 0 0 GAL. BOX W Q MA SHED STONE
SEPTIC TANK �}- 1 fl 0.50 INDICA TES
-32 -4844 FCa LOCATION OF
6
1 B00 2
UNDERGROUND UTILITIES.ES. TAhd'C 6 D-BOX TO BE SETJN A "f 0 TEST PIT
6 BED OF C WPACTED 09G.WW STONE.
5. DATGW IS N 6 V I? G>;YYTRACrag TO MATE TES1�0-BW TO P". .SA.S, : � I
7. NO DETERMINA TION HAS BEEN MADE AS TO COWL LANCE 0 S�
XITH DEED RESTRICTIONS OR ZONING REGULATIONS. �� �/D 2�
IT SHALL REMAIN THE OMNER'S RESPONSIBILITY TO
.St
/� �« -- SATE. 6,t7• 02
!OBTAIN ALL REQUIRED PERMITS, SPECIAL P&lMITS, u— Depth from Surface Soil Horizon Soil Texture Sal Color Soil Mottling CAS�,�L L,pru SU R.y N
VARIANCES, ETC. FOR THIS PRO✓ECT. 9 9- - 1�-�-
TT�� �� (Inches) TEST BY- _H • N-R1f1LFas, Sol]-
TO
B. IT SHALL REMAIN THE OMNER'S RESPONSIBILITY 1`'��� 6� � � (USDA) (Munsell)
HA YE THE PROPOSED DMEL LING FOUNDA TION 1✓I T/✓EBBED BY.'
DESIGNED TO ACCOUNT FOR TXF EXISTING GRADE _
AAd9 SOIL CONDITIONS AT THE LOCATION OF THE D N �! (`j--��! I L i UN DE COMF45 OAWR4 TD`- nl� c y9w �,
PROPOSED DMELL INS. PERC. RA TE _� MIN./ IN. �u C 1 ST�Zpr'l'A
r Law.$ 314113 a 6 LT ahIn 7'L5 R DESIGN CRITERIA.•
A �� �7-- / �,�� ' DESIGN FLOW'New a ' 1 /-� 2- BEDROOM DAELLING 110 GAL/DAY PER B000M
rwect av " EQC 'L S 2�.0 GAL S. PER DA Y.
6L�.vie..bod Cott, s!1�
- N D
e ✓.�•+•49W Ave o► " �v� �f3/�'� SEPTIC TANK REQUIRED,'
! l� 2.2. GPD X ZOO r � SAL.
�r SY ' n u) Cl -�t ll / �- �� T
al 1 / ,r SEPTl C TANK PROVIDED.' _ 1500 GAL.
SZ7F rc* -,4 F,4Cri ry
cc� ;�rf�L`�d it C ! DESIGN P AC. IrA TER 5 MINUTES/INCH
B.M. TOP OF STAKE FOUND '(�
EL. - 96. 34 (NG 1/D� 2�-� GALL O,'JS P&i DA Y
,/ 7-51 i
`w SIZE OF LEACHING FAC L I Y PR VID D.'
1Q0. 00 r cat, Q'
T.P. ? 1Or �. G.NipOS 3 MLS$ IN, �� �GRET3G
-t 790 W61-e 2 �, ti-�` S-s'o ens
LOT 113 - SIDEWALL t 5= S.F. X a�� - ►l) GPD
h�i6 s'J' 20999-- S.F. + Lr tea'' = L' �, BOTTOM' 3Z S.F. X o.1 ..?140GPD
I oa TOTAL S S.F. GPD
-r4l A L_OT 115 � gTR.1C.Y�,p
F
_ _�Q,oP. c��s-c-ovt� '°� 2 S To A 2.-13�VV94 4
� � �Jv1�Ld..•1�1G
Rec� r 5sv rpt:.
STAR'MwAr`S'�R �u�c�•C-F Tc�-�� a,
' - $,�. - �;,,,; - � � �� ! o e� ,. Q�o'P• 5 •�c - S • .9E VISIONS.• �
;J0. DATE REVISION
OF
kn 9
64' �, 1�•1'#'� t),G tAm S.A.S. TU 330 WID MIN • �
it 4.
4(p� U LR
YY "S"OP 7�b1-► ' _.. • MICF:NIEWICZ r r
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N r.30420
v'
' �... ��•t7b � � � � ,Q� "::NIL
1 7.1 'ot '
DA TE PR 5:"J!AL ENGINE CIVIC
EXIST.
h'ELL
.1.40. 1i : haA +r1�
PLAN SHOWING THE DESIGN OF A PROPOSED
---------��w _SON ENIJE -- 1---------
-�� ` -`�' SUBSURFACE SEPTIC DISPOSAL SYSTEM
-----___ -- a -- -- , N if LONDON AVENUE BARNSTABLE, MA
GRAVEL LOT .1.13, E ,
---------- - ------____-_____-..__-____-�---------- '�r ,1 JUNK" 27, 2002 SCALE .1 u - 30 '
�,� CANAL LAND SURVEYING
way Y��h+-s-� l.o�' 306 OLD PL YMOUTH ROAD, SAGAMORE BEACH, MA
(�
S .�cv►Ct DATE P OFME'310 AL LAN E R PROJECT NUMBER 02- 63