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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r
M 18 Cypress Point
Property Address
William Smith
Owner ✓ Owner's Name
information is required for every Cummaguid MA 02637• 3/23/14
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.-
Important:When
filling out forms A. General Information
on the computer, I
use only the tab 1. Inspector: �J
key e you e to move r
cursor-do not Kevin Cochran
use the return Name of Inspector
key.
Aardvark Environmental Inspections
1 :A Company Name
P O Box 896
Company Address
East Dennis MA 02641
Cl /Town
State
City/Town Zip Code
508-385-7608 13356•.
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time ofthe inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
®, Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
03/26/14
Ins 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.
ly .
t5iru•3/13 7rtle 5 OFidal InspecrF &A�
face Sewage Disposal System•Page 1 of 17
,
Commonwealth of Massachusetts
Title 5 official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Cypress Point
Property Address
William Smith
Owner Owner's Name
information is required for every Cummaguid MA 02637 3/23/14
page. Cityrrown State Zip Code' Date of Inspection
B. Certification (cont.) i
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"hot
determined,"-please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or hot)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 f ❑ N ❑ ND(Explain below):
t5ins•3/13 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
M 18 Cypress Point
Property Address
William Smith
Owner Owner's Name
information is required for every Cumma quid MA 02637 3/23/14
a e. Cityrrown State Zip Code Date of Inspection
P9 P P
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health);
❑ broken pipe(s)are replaced ❑ Y '❑ N ❑ ND (Explain below): '
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y' ❑ N ❑-ND(Explain below):
❑ The system required'pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ T ' 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.•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Tile 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 18 Cypress Point
Property Address
William Smith *'
Owner Owners Name
information is umma uid MA 02637 3/23/14
required for every C 4 '
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 noother failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
r
r
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
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
1-1 ® 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 1h day flow
t5ins•3N 3, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
l
Commonwealth of Massachusetts
Tile 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�t 18 Cypress Point
Property Address
William Smith
Owner Owner's Name ,
information is required for every Cummaquid MA 02637 3/23/14
page. City1rown State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El ® 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. y
❑ ® 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.
❑ 19 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 ZoneII 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
g 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•3113 Title 5 official rnspedion Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments'
M > 18 Cypress Point
Property Address
William Smith
Owner Owner's Name
information is required for every Cummaquid MA 02637 3/23/14
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.
E El Determined in the field (if any of the failure criteria related to Part C'is at issue
approximation of distance is unacceptable),[310 CMR 15.302(5)]
D..System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 official -inspection ForM
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Cypress Point
Property Address s
William Smith
Owner Owner's Name
information is required for every Cummaquid MA 02637 3/23/14
page. Citylrown State Zip Code Date of Inspection
D. System Information _
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes Z No
information in this report.)
Laundry system inspected? ❑ 'Yes ® No
Seasonal use? ❑ µYes ® No
Water meter readings, if available last 2 ears usage d
Detail:
Sump pump? _ ❑ Yes- ® No
Last date of occupancy: CurrentDate
Commercial/industrial Flow Conditions:
Type of Establishment:
F 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Tile 5 official Inspection Form
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
M 18 Cypress Point
Property Address
William Smith
Owner Owner's Name
information is required for every Cummaquid MA 02637 3/23/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date.
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,'volume pumped: gallons
How was quantity pumped determined?
. Reason'for pumping: -
Type of System:
® Septic tank,.distribution box, soil y
absorption system
P
❑ Single cesspool
❑ Overflow cesspool
❑ Privy' t
F
❑ Shared system (yes or no)'(if yes, attach previous inspection records, if any)
El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 or 17
Commonwealth of Massachusetts
Title 5 official Inspection Form'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Cypress Point
Property Address
William Smith
-Owner Owner's Name `
information is
required for every Cummaquid MA 02637 3/23/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
05/15/74 per BOH
Were sewage odors detected when arriving at the site? s ❑ Yes ® No
Building Sewer(locate on site plan): v
1.0
Depth below grade. feet
Material of.construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line:, feet s
Comments(on condition of joints, venting, evidence of leakage,-etc.):
Septic Tank(locate on site plan):
Depth below grade: 0.5
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: 1000 gal
4f'
Sludge depth:
tSins•3113 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 18 Cypress Point `
Property Address
William Smith fi
Owner Owner's Name
information is required for every Cummaquid MA 02637 3/23/14
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 28,
Scum thickness r
5„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffl1511e, '
How were dimensions determined? Measured
Comments(on pumping,recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was sound and tight with tees in-place and liquid at outlet invert.
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
l5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Cypress Point
Property Address
William Smith
Owner Owner's Name
information is Cumma uid n:" MA 02637 3/23/14
required for every q
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee o.r baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete - ❑ metal ❑fiberglass: ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons •
Design Flow: v gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes, ❑ ,No '
Date of last pumping:. 1
- - Date
Comments(condition of alarm and float switches, etc.):
• r
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113, 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
M r< 18 Cypress Point
Property Address
William Smith
Owner owner's Name
information is required for every Cummaquid MA 02637 3/23/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) "
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal,any evidence of.solids carryover, any
evidence of leakage into or out of box, etc.):
No box present
Pump Chamber(locate on site plan):
Pumps in working order: El, Yes ❑ No*
Alarms in working order: ❑ Yes' ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why: r
t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
18 Cypress Point.
Property Address i
William Smith
Owner Owner's Name
information is required for every Cummaquid 7 MA 02637 3/23/14
page. Citylrown 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:
❑ Teaching fields number, dimensions:
❑- overflow cesspool number:
❑ innovative/altemative system
2 Type/name of technology:
Comments(note condition of soil,:signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
This system has a 6'x6' precast pit surrounded by a foot of stone.There was 2.0 feet of liquid in the
pit with staining just above.
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
r Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1
Commonwealth of Massachusetts
Tile 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary.Assessments
18 Cypress Point
Property Address
William Smith +
Owner Owner's Name
information is Cumma uid MA 02637 3/23/14
required for every 4
page. City/Town State Zip Code Date of Inspection
D. System Information (cent.)
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
r
Depth of solids _
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
r
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 18 Cypress Point
Property Address "
William Smith
Owner Owner's Name
information is
required for every Cummaguid MA 02637. 3/23/14
C' rr wn
page. �Y o 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
18 .
22
31
'43
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
- a
s
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 18 Cypress Point i
Property Address
1
William Smith
Owner Owner's Name
information is required for every Cummaguid MA 02637 3/23/14
page. City/Town State Zip Code Date of Inspection
D. System Information(cont.)
Site Exam: -
® Check Slope
f
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
feet -
Please indicate all methods used to determine the high ground water elevation:
❑ 'Obtained,from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with'local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 or 17
Commonwealth of Massachusetts
Ville 5 Official Inspection Dorm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Cypress Point
Property Address
William Smith
Owner Owner's Name
information is required for every ummaq C uid MA 02637 a 3/23/14
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Y
® 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
s
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
A
Commonwealth of Massachusetts';
Title 5 Official Inspection Forme @ � .
Subsurface Sewage Disposal System Form -Not for Voluntary=Assessments t�
.. L 0
t 18 Cypress Point,
o nt Cumma uid
Property Address ,.
Stephanie Brennan
Owner Owner's Name Y
information is 147 Hutchins Road, Carlisle MA 01741 September 9,2008
required for every P
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.
Important:When
A. General Information
filling out forms
on the computer,
use only the tab
key to move your InSpeCtOr:
cursor-do not Troy Williams
use the return
urn Name of Inspector .
Troy Williams Septic Inspections:
Company Name
19 Hummel Drive
Company Address
"n South Dennis 'MA, 02660-
CitylTown State. Zip Code
(508) 385-1300 S1682
Telephone Number License Number
B. Certification ;
I"certify that I have personally inspected,the sewage disposal system at this address and that the
information reported below is true;accurate and complete as of the time of the inspection.The inspection
was performed based on my,training and experience in the proper function and maintenance of onsite
sewage disposal systems. I am a DEP approved'system inspector pursuant to. ectiont1:5.340 of
Title 5(310 CMR 15.000).The,'system,y,
® .Passes
❑ Conditionally, ❑ Faft
❑ Needs Further Evaluation by the Local Approving Authority
ro 7
CID
September 9, 2008 :Ln
Inspectors Sign 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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system ownershall submit the"
report to the a ro riate-re ional'office of the DEP. The original should be sent to the system owner
P PP P 9y
and copies sent to the buyer, if.applicable;:and the approving authority.
N ****This report only describes conditions at the time of inspection and under the conditions of use ,
at that time.This inspection does.not addressf how the system will perform in the future under
'the same or different conditions of use.
g5
18 Cypress Point,Cummequid•03/08 Title 5 Official Inspection Form Subsurface Sewage Disposal$yslem Page 1 of 15
;} ., - -
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Yr
F +V's "� '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System For _Not for Voluntary.Assessments
M 18 Cypress Point, Cummaguid
Property Address
Stephanie Brennan
Owner Owner's Name
information is 147 Hutchins Road, Carlisle ,MA " 01741 ` September 9, 2008
.required for every
page. City/Town State Zip Code Date of Inspection
{
B. Certification (cont.) p
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',
System meets minimum standards set by Mass DEP at the time of inspection only. This inspection is
not a guarantee or warranty on the future working,con,ditions'of leaching, pipes or components.
f ' 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.
Answer yes, no or not determined:(Y, N, ND) in the ❑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.
ND Explain: .
N/A
❑ 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
obstruction is removed
18 Cypress Point,Cummaquid f03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
r
Title 5 official Inspection Form 3
Subsurface Sewage Disposal System Form ='Not for Voluntary Assessments w
18 Cypress Point, Curnmaquid
M .
Property Address
r ;
Stephanie Brennan
Owner N Owner' m s Name ,
Information is 147 Hutchins Road,Carlisle MA 01741 _ September 9,2008
' required for every e, _P '-
page. Cityffown,, State. Zip Code '.. - Date of Inspection
S. Certification (cont.) 4
B) System Conditionally-Passes (cont.). 4
El 'distribution_ box is leveled or replaced " 1..
ND Explain: .`
❑ 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):•
El broken pipe(s)are replaced
t`
P obstruction is.remo4ed`
s, ND Explain:,f
•. .... '. - A, of
C). Further Evaluation is Required by the Board of Health: ' t`
❑ 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 3.10 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
❑ 4Cessp9ol or:privy.is within 50 feet of,a bordering vegetated wetland or a salt marsh -. '
. 2. System will fail unless the Board of Health(and Public Water Supplier, if any)`
determines that the system'is functioning m a manner that protects the public health,
safety and.4nvironment:
❑ ,The system has a septic tank and sod 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. F I
18 Cypress Point,.Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sawaga Disposal System•Page 3nf 15 ,
�. ;
Commonwealth of Massachusetts' -
Title 5 Official lnspecti®n `i`orm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r.
,. .
w 18 Cypress Point, CumYnaguid
Property Address.
Stephanie Brennan
Owner Owner's Name
information is r r
147 H
required for every Hutchins Road, Carlisle MA 01741 September 9,2008
page. City/Town State Zip Code hate of Inspection ,
R'. ..
B. Certificatiom(cont.)
C) Further Evaluation is Required by the Board of Health (cont):: -
Q 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: N/A ,
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the'presence of ammonia.nitrogen and nitrate`nitrogen is equal to or
less than 5 ppm, provided that no failure criteria are triggered.A copy of the analysis must be ,
attached to this form: �. , ..
3. Other. .Y .
D) System Failure Criteria Applicable to All Systems: `
You must indicate"Yes"or"No"to each-of the following'for all inspections::
Yes No J
;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 overl(jaded.or clogged SAS or cesspool .
® Static liquid level in the'distribution box above outlet invert.due to an overloaded
El
or clogged�SAS or cesspool
® Liquid depth in cesspool is less than 6.7 below invert or available:Volume is less
than '%2 day flow
Required pumping more than 4 times in last year r NOT due to clogged or
N 0 ® _•obstructed pipe(s). Number of times pumped:
•; ® a 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.
18 Cypress F'oint,Cummaquid•03/08 Title 5 Official Inspection Form:RSubsurface}Sewage Disposal System Page 4 of 15
.ram ,
- ... Tyr ��V �£.-h� 4•C Y .j' t .. '6' •�
4 .:
Commonwealth of Massachusetts
Y
Title 5 offical -In�pection Form
u
Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments
18 Cypress Point,VCummaquid
Property Address
Stephanie Brennan
Owner Owner's Name
information is
required for every 147 Hutchins Road,`Carlisle MA �w 01741 September 9, 2008
—
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) 1
D) System Failure Criteria Applicable to All Systems_(cont.):
Yes No $
Any portion;of a'cesspool or privy is within a Zone 1 of a Public vuell.A
z ❑ ® Any portion.of a cesspool or privy is within 50 feet of a private water 'supply well, }
El ® An "ortion of a cesspool or riv is less than 100 feet but gre
ater 50 feet
YP . privy 9.
from'a private water supply well with no acceptable water quality analysis, [T S
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.],, Y.
The system, a cesspool serving a,facility with a design.flow of 2000gpdR
® 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,,therefdrfore the s,,1`6 ails. The
' system owner should contact the Board of Health to determine what will be
.. necessary to correct the failure,
E) Large Systems:• 7o 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. r
Yesy No •
- El 0 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
t
®' the system is located in a nitrogen sensitive area;(interim Wellhead Protection
Area IWPA)or a mapped'Zone 11 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 anylarge
system considered a Sig nificantthreat under Section E or failed under Section D shall upgrade.the
' system in accordance with 310 CMR 1.5.304.The system owner should contact the,appropriate'.
regional office'of the Department. '
18 Cypress Point,Cummaquid•03/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 5 of 15,
r v .k
ti Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Cypress Point, Cummaquid
Property Address.
Stephanie Brennan
Owner Owner's Name
information is 147 Hutchins:Road, Carlisle MA' 01741 September 9;2008 `
required for every '�
page. Cityfrown r•..' 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
` ❑ ' 0 'Were any-of the syste-m components pumped out in,the previous two weeks?
0 . ® Has the system received normal flows in the previous two week periods•
El -MHave large.volumes of water been introduced to the systemsecently or as part of
this inspection? r
Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® 6 Was the facility or dwelling inspected for signs of sewage back up?
® El Was the site inspected for signs of break out?
® 0 Were all system components, excluding the SAS, located on site?
®. El 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? ~r "
® 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 an if of the failure criteria .related to Part C is at issue
( Y
approximation of distance is unacceptable) [310 CMR,15.302(5)]r
18 Cypress Point,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 6 of 15.
Commonwealth of Massachusetts
n
_ Title 5 Official Inspection Fo m..
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Cypress Point,Cummaquid
Property Address
'Stephanie Brennan
Owner Owner's Name
information is 147 Hutchins Road, Carlisle MA 01741 September9,.2008
required for every .•
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design). 4 - Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd .
Number of current residents: 0( .1 prior)
Does residence have argarbage grinder? ® Yes ❑ No
Is laundry on a.separate sewage system? [if yes separate inspection required). ❑ Yes ® No
Laundry system inspected? Yes ❑ No
Seasonal use? ❑ Yes .M No
Water meter readln 's, If available last 2 ears usage d 07,=24,000gals
9 t y 9 (9p )):R 06=17,000gals
Sump pump? t El Yes ® No Y
Last date of occupancy: July 08
Date
Commercial/Industrial FIow,Conditions:
TYpe.of Establishment. y N/A
Design flow(based on 310 CMR 15.203)`. N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq,ft., etc.): N/A
_ - r
Grease trap present? El Yes ® No
.Industrial waste holding tank present? � ❑ .Yes ® No
Non sanitary waste discharged to the Title 5 system?. ❑ Yes M No r`,
Water meter readings, if available-.. N/A
Last date of occupancy/use: Date
Other(describe): N/A
18 Cypress Point,Cummaquid•03108 Title 5 Official Inspaction Form:Subsurface Sewage Disposal System Page 7 of 15
Commonwealth of Massachusetts
a _ Title 5 Official Snspec�ti®n Form
s a Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
,.' 18 Cypress Point, Cummaquid y
Property Address
Stephanie Brennan
Owner Owners Name
information'i 147 Hutchins Road, MA 01741.` September required.for every F � P '
page. Citylrown State Zip Code, Date of Inspection
i D. System Information (cont.)
General Information ,
Pumping'Records: ,.
Source of information: No pumping info avaiable.
Was system pumped,as part of the inspection? El Yes. No
If yes,volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping; N/A
. - 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:
Tank,d=box;& leaching were,installed on 8/8/94 per compliance.:
Were sewage odors detected when arriving at the site?, El Yes M, No
18 Cypress Point,Cummaquid•03/08' Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of.15
Commonwealth of Massachusetts. +
Title 5 Official Inspection-form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
18 Cypress Point, Cum►naquid
Property Address i
Stephanie Brennan
Owner Owner's Name r a
information i t s
required for every
147 Hutchins Road, Carlisle P
MA- 01741 September 9, 2008
page. City/Town �t State ' ' Zip Code Date of Inspection ,
D. System lnformation (cont,)
Building Sewer(locate on site plan):'
r,
18"+.
9
Depth below grade:
-
P
• ,. - _ feet
Material of construction: - f
❑ cast iron . ® 40 PVC ❑ other('explain* ):
N/A:.
Distance from private water supply well.or suction line. f
.:feet
{ Comments (on condition of joints, venting, evidence=of leakage, etc.)'::
Flushed lines and found clear at the time of inspection.
Septic Tank.(locate on site plan): i
Depth below grade:
feet
Material of construction. .
. ❑fiberglass'. ❑ polyethylene ❑ other(expl e ,
" t ® concrete.; ❑metal w ain)
• .•. y. 1. n f '• • .. _ � - r
If tank is'metal, list age: $k r ;, .,; N/A
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) . µ El ❑ No
.--- --.- - •z_- - -;.-- - -- ----- ------- a,---- --- ------- ---— -------------- ----------- -
b Dimensions: &X 10.5'X 6' 1500 gallon
- '- .� `- —
t .
Sludge depth:. . 4,, '
Distance from top of sludge to bottom of'outlet tee or baffle' C1
Scum thickness t g
Distance from top of scum to top of outlet tee or baffle u
,,,,Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? }'Probe/.Measured
18 Cypress Point,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection ,Fora
o Subsurface Sewage Disposal System Form Notfor Voluntary Assessments
A _ F
18 Cypress Point, Cummaquid' ..:
Property Address
Stephanie Brennan
Owner Owner's`Name
information is x
requiied for every 147 Hutchins Road, Carlisle , MA 01741 :. September 9, 2008 -
page. Cityrrown 'State Zip Code ;: Date of Inspection
D.-System Information (cont.) '
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc inlet and outlet tee's were present.:No'evidence of leakage or damage was found. Pumping of
tank is recommended at this time:
Grease Trap(locate on site plan)' a :-
Depth below grader N/A
„1� feet:. -
Material of construction:
❑ concrete ❑`metal ; ❑ fiberglass ❑ polyethylene ❑ other(explain)-.
N/A
Dimensions: N/A r
N/A J.
Scum thickness
Distance from top of scum to top of outlet tee or,baffle
N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
- Date of last. pumping: N/A -
• Date
k Comments(on'pumping recommendations .inlet and outlet tee or baffle condition structural integrity,
liquid levels as'related to outlet invert, evidence of leakage, etc.):
N/A h
the •
Tight or Holding Tank-(tank must be�pumped at time of..inspecktion).(locate on site plan): ;
Depth below-grade: :.
s N/A 5 . r
Material of construction: g
' fy
El
concrete ❑ metal ❑ fiberglass _ ❑ polyethylene ❑ other(explain):
N/A }
18 Cypress Point,Cummaquid-03/08 Title 5 Of U`al Inspection Form Subsurface Sewage Dispose)System Pege 10.of 15
.. .^ Y 4 Y i i T4 d
s � r
Commonwealth of Massachusetts
r Title 5 Official lnspection Form
Vk
Subsurface Sewage Disposal System Forme-Not for Voluntary Assessments
18 Cypress Point,Cummaquid
Property Address
Stephanie Brennan
Owner Owner's Name
information is 147 Hutchins Road,Carlisle MA 01741 Se tember 9, 2008
required for every P
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or HoldingTank(cont.)
Dimensions: 1-N/A
Capacity: N/A
gallons
N/A
Design Flow: gallons per day
Alarm:present: ❑ Yes '❑ No
N/A
Alarm level: Alarm in working order:. ❑ Yes ❑ No
.y' 8
Date of last pumping: Dace
Comments (condition of alarm and floatswitches, etc.).-
N/A
*Attach copy of current pumping contract(required):is copy attached? ❑ .Yes ❑ No
Distribution Box(if present must be opened) (locate on site"plan):
` - Level with
Depth of liquid'level above outletinvert
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.):
D-box was found level and in working order.
Pump Chamber'(locate on site plan):
Pumps in working order.' El Yes ❑ No
Alarms in working order: ❑ .Yesy ❑ No
18 Cypress Point,Cummaquid•03/08 £ : Title 5 Official Inspection Form:Subsurface Sewage Disposal system,.Page 11 of 15
• Y .
a
Commonwealth of Massachusetts
Title 5 Official Inspection Ford .r
' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
'. 18 Cypress Point;'Cummaquid.
Property Address
Stephanie Brennan-
Owner Owner's Name '
information ie 147 Hutchins Road, Carlisle MA 01741 Se tember 9, 2008 required for every _ P '
page. CityrTown < State Zip Code pate of Inspection '
D. System Information (cont:)
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:
N/A t
2._6'x6'pit
Aleaching pits number: w/2`st6ne '
❑ leaching chambers. number:,
❑ :leaching galleries number:;
0 leaching trenches s number, length: .'
El leaching fields . , y number, dimensions:
overflow Cesspool number.
n
El
..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.);
Leach pit#2,was found with 10"of water present with a visible stain+line approx.T below inlet invert.
Water was low in pit# 1.,No evidence,of hydraulic failure or problems in the past were found at the
time of inspection. -
18 Cypress Point,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form,,.,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 18 Cypress Point, Cummaquid
Property Address -
Stephanie Brennan
Owner Owner's Name
information is 147 Hutchins Road, Carlisle MA . 01741 September 9,.2008
required for every _ p
page. Cityrrown S.tate Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site,plan):
Number and configuration N./A
Depth top of liquid to inlet invert NIA
Depth of solids layer N/A
Depth of scum layer N/A
,x
Dimensions of cesspool N/A
Materials of construction
Indication of groundwater inflow El Yes 0 No
Comments note condition.of soil, signs of hydraulic failure,
( g y re, level of ponding, condition of,vegetation
etc.):
N/A -
Privy (locate on site plan):
N/A .
Materials of construction: -
Dimensions N/A.
t
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc..),
N/A
18 Cypress Point,Cummaquid•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1,3 of 15'
Commonwealth of Massachusetts: `.Y
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form'-Notfor Voluntary Assessments
�.w s••'c 18 Cypress Point,Cummaquid
Property Address
Stephanie Brennan
Owner Owners Name
information is 147 Hutchins Road Carlisle 'MA 01741 September 9, 2008
required for every � _ p
page... Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System- Provide a sketch 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.
oaiu•-d-s.f..��'
o
/� ( �„g r(�11 ,° - • ...
P4 `
18 Cypress Point,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
a -
-\
. Commonwealth of Massachusetts - `
Title 5 official inspection F®r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Cypress Point, Cummaquid
Property Address
Stephanie Brennan
Owner Owners Name ..*
information is i 147 Hutchins Road, Carlisle ° fY
. required for every � MA 01741 September 9, 2008,
page. Cityfrown - State Zip Code Date of Inspection
D. System Information (cont.)
.
Site Exam:
® CheckrSlope
El Surface water
Check cellar
t
s
Shallow wells
r
'20'+.
Es
timated to depth I p high ground water: -
.feet
Please indicate all methods used to determine the high ground water elevation.,.
® Obtained from system design plans on record,
5/10/94 F
- If checked, date of design plan reviewed: pate r
'Observed site.(abutting property/observation hole with in.150 feet.of.SAS)
Checked with local BoaFd.of Health -.explain: 7
El. Checked with local excavators, installers:(attach documentation),
® Accessed USGS database -explain:
Al W247 Zone C ` 24.3' 4.8' adjustment
You must describe how you established the high groundwater elevation:
Soil was sandy.Test:hole on plan showed no water found at 19.0'. Groundwater adjustment in area at
the time of inspection was 4.8'.'Bottom of leaching at 10.3'was found not to be located in the high
groundwater elevation at'the time of inspection.USGS Map,showed groundwater estimated at 63.3'.
18 Cypress Point,Cummaquid•03108 ` Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-page 15 of 15
IV�o................_....... Fizz...........................
THE COMMONWEALTH .OF MASSACHUSETTS
BOARD OF HEALTH
.................O F�`
�i � i�'✓ ram........ �,�;%" P P �4 .�......................................
Applirtt#inn fnr, ttI Workri Cnnmi rnr#inn Wrmit
e Application is hereby made for'a Permit to Construct (W04-or Repair ( ) an Individual Sewage Disposal
System at:
..... %fa ................
lfifj
n1�Ccs orLNo.
d.
a _- ----•........................ .................... ....... . ...
7( f
; n w Address
v
-TT .0,0-/X,
Installer Address
Type of Building Size Lot .7 ........Be
er
p, Other—Type of Building ...... ......... No. of persons............................ Showers ( ) — Cafeteria ( )
Otheri-_'�rses L '::,
u ................ . ... .........................................
W Design Flow.. .. ...�........ o 'gallons per perso pe'A day. Tota4� flow....................................... .:&9llons.
WSeptic Tank—Liquid'capaci y............gallons Length.. ........... Width .._........... Diameter................ Depth................
x Disposal Trench '. ------------------- W l Total Length. Total leaching area . sq. ft.
Seepage Pit No.............._Diameter...:_.: Depth below inlet... Total leaching area° .�� ..sq. ft.
z Other Distribution box ( ) Dosiva (
�, � lee&
Percolation Test Results. Performed by........................... ...._..:.....-....-........_........ Date--•-.-----...:........................
Test Pit No. I.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
..... .........................................................................•-•.._........................ ......................_.
0 Description of Soil.............................•-•-••........
U .................................................•-•--......--•........................•-••••--•--•.....•---••--••--•--.._...--•---••---•.... ................_.........._•----•--•.............._------
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 Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has AcdtVe'pba�rd of
ned ea ...?..Sig �i ......... �+
Date
ti
Application Approved By.............. .... ..........................................................
�"` *r f—batc
Application Disapproved for the following reasons:---•-----------•..........................•--•--................... .....................................
Ate
1.
Permit No...... _ Issued_.•............. ............ --•--•--------
T' Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.........................
Trr#if irat of f9nmtplittna .
THIS IS TO CERTIFY, That the Individual Sewage Disposal System c 6
onstructed ) or Repaired ( )
by..... �....,. �.....................I ii ..................................
r' "P /, V f� nsta cr
at......................................•-........................--•-..............................................._...................--••-•...........................----.._...•-•............
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...... ✓f-. .._...:-.. ..::.-:.... dated................................................
:>
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i .
............�:�` r f .. .....oF.`...........�� '� c o.n .................................... FEE. . . ........
....... .. .....:... ....
�in�nnttl nxkn �nnn�•nr#inn ��ermi�
Permissionis hereby granted.......... `..... - = ...... ....................... ....................:...................._..........
a -7y
to Construct ( ) or Repair ( ) an Indivr'idual Sewage Disposal System
at No.............t*i. a",y * ..............,
-•- . l .::.................................................. ....._.......S 0,
treet
as shown on the application for Disposal �'Torks Construction Permit No...%f!......4.�Datcd.........:7!......i -..... ........
..............................••........---......----•-------...............................-----•....._
Board of Health
DATE...................................................... ..............
FORM 1255 A. M. SULKIN. INC.. BOSTOV.,
11O'11{{
WN OF BARNSTABLE
LOCA'ION SEWAGE # 1"y� 71S
VILLAGE C�t/me"144 vlo ASSESSOR'S MAP & LOT Oyg -61,6
Ilk INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) / (size) G
NO. OF BEDROOMS PRIVATE WELL OR BL1C WATE
DATE PERMIT ISSUED: l y
DATE COMPLIANCE ISSUED:
VARIA:+ICE GRANTED: Yes No
6
T j '
FRic Lap.._........ '
THE COMMONWEALTH OF MASSACHUSETTS
�r
•�, BOARD OF HLALTH
pplirathin for Bispaaai lVark,5 Tanstrnr#ion Vnmit
pplication is hereby made for a Permit to Construct ( u-)"or Repair ( ) an Individual Sewage Disposal
System at• � ��f��wl..............
............. .. �.�.3 5........!!i< 7t �l l� .----•-..... �O.�:.� .:. O�' ........... ._-•-•-
:..
//���� L ration•Addiresf - -•.or Lot No.
�0"a Installer Address �qp
Type of Building ize Lot. 7. J......Sq. feet
Dwelling—No. of Bedrooms
............................Expansion Attic (✓ Garbage Grinder (!��
aOther—Type of Building ...... .... No. of persons...........:................ Showers ( ) — Cafeteria ( )
Otherfix ................/-............:,.........................._...._...----.-_..�........._......_..
W Design Flow......... .................gallons per person e{d'Sy. Total (hAl /Row_._ ............................,.�lons.
Rr Septic Tank—Liquid*capacity," ..gallons LengthA..c!--.._. Width-5 q..... Diameter................ Depth3 P.......
W Disposal Trench—No.......... Width....^.._.........Total Length... ............. Total leaching area....................sq. ft.
x ( ( )
Seepage Pit No....Y........ iameter./Ox Q.... Depth below inlet_ ..:.... Total leaching area.��.Ysq. ft.
z
Other Distribution box °� Dosingtank ��
`" Percolation Test Results: Performed by--... ........ ........ ............•--........._.....__......_. Date_...'._/o .....
................
aTest Pit No. 1.......:........minutes per inch Depth of T t Pit..........____._.... Depth to ground water.._.....................
(z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
..........
----•...................••------•..-.--....--............. -----------
.......
---••-..................._..........
---------
•.......
....
0 Description of Soil..................•--•--.............................-•-------..........----.....---••---.....---•--........................_.....__._...._......---....-•-------.---_..
U ............................................................................................................. .............. ....................................................................
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 TITIZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasjb y rd
Signed. ... _ ................ �._. Date
A lication A roved B .. ...... .. .. •................................ �7
Date
Application Disapproved for the f ollowitxyo.:reasons:.................................................................
............................................................•--.... ......................................_...................... Date .
Permit No...... s .. ..,`'�. -- Issued.... v........ ..
1 .... ;
E COM
�Nt»1A4�rfJ �
SEPTIC TANK LEACHING PIT
t .
TOP Of FAVNDATIAN Piro
EL F>w-w Gy wxOVER LsAmlNG
.
a
Gi?" b141QYES AF* AUXt' f1�1//S�_N OVA DE r�y�
MWtif Ffrav //4 PER FOOT "-l%2 N
SER ...._�_
- �. 3 OIL //S
l Qti�• MIISMV PEASTOWE ; • .
LOCUS MAP :4• •a'�
v� 0 0000 p 4po
0000
W
�� � , ,,: � �. •�. d d d o 0 Oo 0 ° %•�' d d o
Gv aw PRECAST ! 6 p o Q o 6.0 0 0v 0
BASEMENT :Q:.4, :• ATE H-/0 f7Nft�Rl' 'D O C V
�= OUTL T PIPE TO BE OQ {'
EL.= E
LEVEL FOR TWO FEET 00000 ROAST G10V4GniETE 0
}: 0 1 o
�o BALANCE PAN 'D' BOX *ME o �p0 c0 O p Qn7.
•• V
0 ` TYPE ST/, C-0 o O��NSIO d I , , S OAtr O�031
LENGTH/" THJNE1aHT v Q� �..�.
0 , a o fEET (W
aa .� -D 6 •o z• 4
/%'STONE
�D �•` ON BOTTOM
7- ?t � � py EFF?L"�rVE L�AMETE7P ,�
�• � � ELF.�:�..._...
' - SOIL PIDORLES hfAX.ON. EL
P_ �.Z3� SOIL MORPHOLOGY
I V wZ Z3 •.
TP" TP" TP //1
DESIGN CR/TiL�R
o0
o t 'Sd -3o YvboiJ.(oA/J s�1 , o _- 3e) Of S v
7.. �- - ..__
WSW DI0OS&- rF .- ..A -X—
�� —- rO7& =IWED &P.D.
f arfi ItAwv Am rnf..AIAM./NNm
h R Or LEACMW RATS-A&
3 !
SVENI4L.L AWAA•n?1JrPH•188
IS �SCZA Fe74
s
OPW
^ > SA✓/): 3��d BLOT rom ARM& I/R r r t
78 Sf.X:. 6.1 /SF.�►
i �• � � � � /� .J/jA/P �� �`.____-_ _�(�F.S_.sifi✓/���,(lq,�' -`��------- ry PITV►If/f-Ot•�._z C%P.V.
lime
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NOT
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i
08SERVA70V PI M FLo�o,� RaA/�•
� SETBACKS-' FRONT-2�).SIDE REAR� .
6ri4141D of IimTN ASSESSORS MAP-39,,— LOT 4�
—.., E7IR^,AIIITUR . r% �'� ELEVATIONS BASED ON:
LEGEND
-- S= . NOa:21
EXISTING CONTOURS — — — — -
- �� 1. THE SEPTIC SYSTEM SLL CONFOM TO ALL
,�o T i,F7 PROPOSED CONTOURS - STATE AND LOCAL REGULATIONS;
A. REMOVE ALL UNSUITABLE MATERIAL FOR .
WATER LINE W W EROSION CONTROL METH008 FEET. IN ALL DIRECTIONS AND 'TO AN
f•+•�(Minimum) ELEVATION OF, AND BACKFI.LLEO IN
COMPLIANCE WITH; 31,0 CHAR 15:02 (7).
B. A L PIP #`�j T0. 8E�..INCH, 8C1•�. 40 PIPE,
6.. During construction all bare and denuded soil is to 0 C• 1• •
be covered with one of the following if the slope C. PRIOR TO BACKFILLING THE
is 1 ess •than 3-1 , BOARD OF HEALTH SHALL h1OTIFIED.
6'-7 S 'A a. straw mulching
f , fa0 b . 'wood chips D• WATER SUPPLY PROVIDED BY
}.
c . straw matting 1 aid parallel to grade and ALL DISTANCES TO BE MAINTAINED.
hold in place by metal staples E WATER ADJUST�IEM.TS 8ASE0 ON U.S•S.S.
d . Lawn mixture to be spread , rol 1 ed , E.
watered , and covered by either a or c . .
2) During construction all bare and denuded soil with .• ------••r!•�--
slope grades in EXCESS of 5% shall be protected from erosion
1; by the fol 1 owing i F',l .42
2� a. Lawn mixture of 60% annual rye grass, 20 �� •
fescue , and 20% blue grass shall be laid over a minimum 3
inch layer of topsail , rolled , and watered .
3 b . Seed mixture to be protected from erosion
by covering with either hay mulching which is covered and
Held in place by netting , or standard straw matting or
geotech fiber matting held in place by staples. SITE aim 49 S&WC DE9W
•d .• Si 1 t fence to be used at the toe of slope r
and the bottom of fence to be anchored into the ground . LOT (/. 4
d . Measures designed specifically to the
site. C �iS_S �o/A1T;
3) Protection for all ROADWAY frontage to consist of '
the followings APPLICANT
a . Gravel berms of one, and one half inch •
„+ a� washed stone to be placed around the catch basin orate.
'�� '." P ''•" b . Galvanized hardware cloth with one inch UPPER CqW"vAvWAF 016WEEfiWe
r ,)A holes to be placed over grate and anchored with bag ties.
��..-. • ' ° r`. c . Cleaning of cloth and replacement of PO BOX 6/6
• 1$ r stone to be done when conditions warrant . E. VA VI,�,
d . Al 1 driveways within the Town right of
- ✓ ;i way to be maintained by use of a gravel apron per Town
Engineer's specifications. VAS• �
e. All -siltation All - siltationg mud , and other debris
caused to enter the Town roadway is to be rwwovbd at the � -
cost of the contractor. OIMVxowl ..
!
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