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chusetts Commonwealth of Massa
�- Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address'
Fratantonio `
Owner Owner's Name c.
information is /
required for Barnstable ►/ MA 02630 . 10/24/18
every page. City/Town State Zip Code Date of Inspection
Ua
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.
A. Inspector Information . 9
Frank Nunes 111
Name of Inspector
saa
Company Name
Box 841
Company Address ,
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 „
10/24/18
Inspector's gnature y 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
x 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 ;
(P Title 5 official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u 103 Dromoland Lane
Property Address {
Fratantonio
Owner information is Owner's Name -
required for Barnstable MA 02630 10/24/18
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist,Any failure criteria not evaluated are
indicated below. .
Comments
., z
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
6
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Owner Fratantonio
information is Owner's Name
required for Barnstable MA 02630 10/24/18
every page. Cityrrown 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 1S
Commonwealth of Massachusetts
IF Title 5 Official Inspection Form'-
1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Fratantonio ,
Owner Owners Name
information is
required for Barnstable MA 02630': 10/24/18
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption.system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well. .
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
.more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.. e `
c. Other: ti
.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
El ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Forte
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Owner Fratantonio -
information is Owner's Name
required for Barnstable MA 02630 10/24/18
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4 System Failure Criteria Applicable to All Systems: (cont.)) PP Y (
Y
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
❑ ® or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is.iess
than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ .® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El ® 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.
❑ Z 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.
- ®f 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 it of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts w
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Dromoland Lane
A
Property Address
Fratantonio
Owner
information is Owner s Name
required for Barnstable . MA 02630 10/24/18
every page. Cityrrown 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'
- t
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) r
® ❑ 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.
t ® - 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
chusetts Commonwealth of Massa
F Tile 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `
103 Dromoland Lane
Property Address
Owner
Fratantonio
information is Owner's Name ,
required for Barnstable MA 02630 10/24/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:.
Number of bedrooms(design): Na Number of bedrooms(actual). 4
-110 example:for DESIGN flow based on 310 CMR 15.203 d
( p 9P x#of bedrooms): n/a
Description:
4 bedrooms per owner, no engineering on file, certificate of compliance states 3 bedrooms, permit
was not completely filled out
Number of current residents:
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:'
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? [I Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): a
Detail:
Sump pump? ❑ Yes'® No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Dromoland Lane
Property Address } ;
Owner Fratantonio
information is Owner's Name
required for Barnstable MA 02630 10/24/18
every page. Cityrrown 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)- w Gallons per day(gpd) /
Ir -
Basis of design flow(seats/persons/sq.ft., etc.): _
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? Y ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? . ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ,r. ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: date
Other(describe below):
3. Pumping Records:
Source of information: Pumped 2016 per owner.
Was system pumped as part of the inspection? ❑ Yes ® No
` If yes, volume pumped: aeons
- 9 ,
How was quantity pumped determined?
Reason for pumping:
t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
P Pe 9 P Y 9 i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Fratantonio
Owner information is Owner's Name
required for Barnstable MA 02630 10/24/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, 4soilabsorption 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:
1985 per BOH record _
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
18"
Depth below grade: feet •.
Material of construction: -
cast iron ®40 PVC ❑other(explain)`
Distance from private water supply well or suction line: >10'
feet
Comments(on condition of joints, venting,evidence of leakage, etc.): -
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Fratantonio
Owner information is Owner's Name '.
required for Barnstable MA 02630 10/24/18
every page. City/Town State Zip Code ., Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
12„
Depth below grade: feet
Material of construction:
®.concrete ❑ metal ' ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
3
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a"copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth:
Distance from.top of sludge to bottom of outlet tee or baffle >12"
Scum thickness trace-1/2"
a ,
Distance from top of scum to top of outlet tee or baffle
>2"
>211
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? g measured
Comments(on pumping recommendations,.inlet and outleftee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Foim:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•V 103 Dromoland Lane
Property Address
Fratantonio
Owner Owner's Name
information is
required for Barnstable MA 02630 10/24/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan): _ s
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 g
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 grader
Material of construction:
El 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
103 Dromoland Lane
Property Address
Owner Fratantonio
information is Owner's Name
required for Barnstable MA 02630 10/24/18,
every page. Cityrrown 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):
0"
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.):
D-box is 12" below grade, H-10 box appears to be structurally sound
r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts ;
re Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Fratantonio
Owner Owner's Name
information is
required for Barnstable MA 02630 10/24/18
every page. Cityrrown 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.):
3
*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:
_ 2
® leaching pits number:
❑ - leaching chambers number:
El leaching galleries number:
leaching trenches number;length:
❑ leaching fields number, dimensions:,
❑ overflow cesspool rs number:
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
�h Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Fratantonio f
Owner Owner's Name
information is
required for Barnstable MA 02630 10/24/18
every page. CityrFown 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.):
Pit"C" is full beyond its leaching capacity at this time, Pit"D" has approximately 2'of effluent in it at
this time, sidewalls are clean above the current level, cover raised ton 6"of grade, no indication of
past hydraulic failure, 600g pits
12. Cesspools (cesspool must be pumped as pah 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 cesspools .
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.):
,
n f.
t5insp.doc•rev.7/26/2018 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�tl Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Fratantonio
Owner
information is Owners Name
required for Barnstable MA 02630 10/24/18
every page. Cityrrown 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.):
t
P
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts '
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M
103 Dromoland Lane"
Property Address
Fratantonio
Owner
information is
Owner's Name
required for Barnstable MA 02630 10/24/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
9 P Y 9
landmarks or benchmarks. Locate all wells within 1:00 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below `
❑ drawing attached separately -
r
q
C qo
V > SUc LG_
t5insp.doc-rev.7/262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 18
t .
c Commonwealth of Massachusetts
Title 5 Official inspection Form
Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
103 Dromoland Lane
Property Address
Fratantonio
Owner is Name
information is Owner's _
required for Barnstable - MA 02630 10/24/18
every page. Cityrrown 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. >13'
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: bate
❑ Observed site(abutting property/observation hole within 150 feet of SAS) }
® Checked with local Board of Health -explain:
per permit NGW 13', 4' seperation per compliance on file
❑' Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Site is 70'msl and nearby surface water is 30'msl
You must describe how you established the high ground water elevation:
See above
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 t
103 Dromoland Lane
Property Address
Fratantonio
Owner Owners Name
information is
required for Barnstable MA 02630 10/24/18
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of: ,
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3,or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate _
4 (Failure Criteria)and 6(Checklist)completed
D. System Information:
For 8: Tight/Holding Tank-Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t
f_
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
5 �to/li �� 1 �-y � - 3 3 y
Commonwealth of Massachusetts
Title 5 Official Inspection Form �' ✓ �
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
H 103 Drumolan_d Lane, Cummaquid__-_ —
Property Address -- _ --- ---- �_— -- — —
Paul Healy—_
Owner Owner's Name — -- --------- —.- — _
information is
required for every 441 Warren Street, Needham _ _ _ MA__ 02492 _ _October 27, 2010
page. City/Town j State Zip Code - Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector.
key to move your
cursor-do not Tf6 Williams
use the return - --y----- -- =- -- ------- -- —
key.
Name ofInspector --- --------- ----------- --
Tro r_Williams Septic Inspections
� Company Name - - -------- ------- —
19 Hummel Drive I ,
Company Address
South Dennis MA 02660_
City/Town -- - State Zip Code --
508 385-1300 _ _ S1682
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 95.000). The system:
® Passes ❑ ,Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority , --1
c z C:)
_October 27, 2010
Inspector's Signatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (160rd
of Health or DEP)within 30 days of completing this inspection. If the system is shared_W�sterlldslr
has a design flow of 10,000'gpd or greater, the inspector and the system owns•shall su-mit theme
report to the appropriate regional office of the DEP. The original should be senito the sy*m owner
r -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.
.a
t5ins•09108
Title 5 Official Ins ctlo n Form:Subsurface
, Pe ,, _ Saw.go Dispose l System•Pape 1 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 103 Drum_olarid Lane, Cumm_ayuid_
Property Address ----- --- ------ - -
Paul Healy
Owner Owner's Name
information is required for every 441 Warren Street, Needham MA 02492 October 27, 2010
page. City/Town State Zip Code Date of Inspection
B. certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all.of Section D '
A) System Passes: .
1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 31.0 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments: {
System meets minimum standards set'by Massachusetts DER at the time of inspection only. This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes or
components, or the future structural integrity of system components and represents conditions found
on the day of inspection oniy_
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health; will pass. .
Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain. .
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration°or exfiltration or tank failure is.imminent. System will pass
inspection if the existing'tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a.Certificate of
Compliance indicating that the tank is less than 20 years old is available..
❑ Y . ❑ N ❑ ND (Explain below):
N/A
:
t5ins 09/08 Tithe 5 Official Inspection Form;SubsuYFace Sewage Disposal System Page 2 of 17
< - _ i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Drumoland Lane, Cumma uid
Property Address —
Paul Healy
Owner Owner's Name
information is required for every 441 Warren Street, Needham MA 02492 October 27, 2010
page. Cityfrown State -Zip Code Date of Inspection
B. Certification (cont.) ;
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y• ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced Y. N❑ ND (Explain below
P ❑ ❑ ❑ ( P )
N/A
❑ 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):
N/A
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•09/08 t Title 5 official Inspection Form:Subsurface S#w Qa Disposal System Page 3 of 17
{
j}fpr + 'S t 4•..
{
,
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103 Drumoland Lane, Cum_ rhaquid
Property.Address —
Paul Healy _
Owner Owner's Name ----
information is �.
required for every 441 Warren Street, Needham__ MA_ 02492 October 27, 2010
page. City/Town State Zip Code Date of Inspection
�. 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 aseptic 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 supply within a Zone 1 of a public water
❑ ' 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 DER 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 other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other.
N/A
4
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or-"No"to each of the following for all inspections: ` t
Yes No
Backup of sewage into facility or system component due tooverloaded or
clogged SAS or cesspool. .
Discharge or ponding of effluent.to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® ' Static liquid level in the distribution box above outlet invert.
or clogged SAS or cesspool due to an overloaded
0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
` 7tlle 5 Official Inspection Form Subsurface Sewage Disposal Syster i age or]#}y + Y
i P 4
p}
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103 Drtamoland Lane, Cummaquid
Property Address
Paul Healy
Owner Owner's Name --- —information is 441 Warren Street, Needham MA 02492 October 27, 2010
required for every _
page. City/Town State Zip Code .Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping.more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: N/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.
❑ 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.
❑ . M 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 16,000 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
11
❑ 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,
1f you have answered"yes".to any question in Section E the system.is considered a significant threat,
or answered "yes' in Section D above the large system has failed. The owner or operator of any large
System considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t51ns-09/08 Title 5 Official Inspection Fond Subsurface Sewage Disposal System Page S of 17
9
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
N 103 Drumoland Lane, Cummaquid_�___
Property Address ---
Paul Healy
Owner Owner's Name
information is required for every 441 Warren Street, Needham _ MA 02492 October 27, 2010
_ _
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
M ❑ ' 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?
El ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of wafer been introduced Co the syM6e i 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 backup?
® ❑ Was the site inspected for signs of break out?.
® ❑ Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the'proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]-
D. System Information
Residential Flow Conditions:
} Number of bedrooms(design):. 4------ Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•09I08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page t3 of 17
Commonwealth of Massachusetts
131 Title 5 Official Inspection Form , .
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
IWO a
103 Drumoland Lane, Cummaquid
Property Address ---- ----------- ------ -- --- --- -----
Paul Healy_ _
Owner Owner's Name
information is required for every 441 Warren Street, Needham MA 02492 October 27, 2010
i - _
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a,garbage grinder?~ ,> ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection rrequir
ed] ❑ Yes ® No
Laundry system inspected? ' M Yes ❑ No
easo a s ,S n le u
® Yes ❑ No I
Water meter readings, if available(last 2 years usage (gpd))'
09=130,000 gals.
10=116,000 gals.
Detail:
Sump pump'?.. ❑ .Yes ® No
Last date of occupancy: „ .f occasional use
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: 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
Grease trap present? ❑ Yes ❑ No
Industrial-waste holding tank,present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
N/A
Water meter-readings, if.available: —
t5ins•09/08 J ` Title 5 Official Inspection Form:Subsurface Sewage Dlaposel Systm P Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103 Drumoland Lane, Cummaquid
Property Address --
Paul Healy
Owner Owner's Name -- ----- r —
information is
required for every 441 Warren Street, Needham_. MA ' 02492 October 27, 2010
page. Cityrrown State Zip Code . Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:r N/A
Date
Other(describe below):
N/A
General Information
Pumping Records:,.
No um ing info was available.
Source of information:, - � -- -.
Was system pumped as part of the inspection? ❑ Yes ® No'
If yes, volume pumped: N/A
gallons e
How was quantity pumped determined? NIA
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
❑ .e. Tight tank. Attach a copy of the DEP approval.
Other(describe):
t5ins•09/08 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
usetts
Commonwealth of Massach
Title 5 Official Inspection Form F
Subsurface Sewage Disposal System Form - Not for Voluntary'AssessmentS. "
e,a
pd
103 Drumoland Lane, Cummaquid
-- r
Property Address —
Paul Healy 3
Owner Owner's Name-- — -- — — " ' —information ie 441 Warren Street, Needham_v 4\ MX 02492 `
required for every _ +r.' _ October 27, 2010
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:
Tank, d-box& leaching were installed on 4/1/86 per compliance.
Were sewage odors detected when arriving at the site? s ❑ Yes ® No
Building Sewer(locate on site plan)
Depth below grade:,
P;
feet
Material of:construction: ' F
cast iron ;
® 40PVC` ❑,other(explain) -> -.— •— ;- _ ' ._ '.
Distance from private water supply well`or suction line: N/A
feet
Comments (on condition Of,joints, venting,'evidence of'leakage etc.):,
Flushed lines and found clea(at the time of inspection.:!' e
F
r
rt
Septic Tank (locate on site plan):
Depth below grade: 1 --
+ feet.
. I
..Mat..
erial of construction:
® concrete' s ❑ metal r. ❑fiberglass ❑ polyethylene ❑ oth1.er(explain)
._
^
i
If tank is metal list age: �`'p N/A _
years �• i
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ ,No
Dimensions:r 6',X 10.5''X 6' 1500 gallon
. r
Sludge depth:
t5ms-64/o8 , �f , Tlde 5 Official Inspection Form Subsurface Sewage Disposal System Page g of 17
a
• .. ..,,. -. x ±., fin: : '� , -l...,.
it411
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M r 103 Drumoland Lane, Cummaquid
Property Address
Paul Healy_
Owner Owner's Name
information is required for every 441 Warren Street, Needham MA 02492 October 27, 2010
—_. _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.).
Septic Tank (cont.)
21 8" '
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness Ttiri Layei;
Distance from top of scum to top of outlet tee or baffle
6"
1411
Distance from bottom of scum to bottom of outlet tee or baffle
_ 1
How were dimensions determined? Probe/rrieasured
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 concrete outlet tees were present. No evidence of leakage or damage was found at the
time of inspection. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
- N/A'
Depth below grade-.. feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene Elother(explain):
Dimensions: N/A .
Scum thickness N/A
r
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
t5ins•09/08 Tide 5 Official Inspection Form;Subsurface Sewage Disposal System t page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
"Y 103 Drumoiand Lane, CumMaquid_n_ °
Property Address —
Paul Healy
Owner - - a-- ==-
Owner's Name
information is required for every 441 Warren Street, Needham MA 02492 October 27 2010
_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
N/A
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass.. 0 polyethylene ❑ other(explain):
NIA
Dimensions:
Capacity: _N/A---- __ —
gallons _
N/A
Design Flow: gallons per day
t .
Alarm present: [] Yes ❑ No
Alarm level: N/A
---- — Alarm in working order: ❑ Yes ❑ No
N/A
Date of last pumping: Date _
Comments (condition of alarm and float switches, etc.):
N/A
Attach copy of'current pumping contract (required). Is copy attached?. El Yes ❑±No
j
t5ins•09/08 Tula 5 Official Inspection Form:Subs,f aFa Sawage.Dlsposal System Page 11'of 17
A �
as ra i Vat a ra p q .Irk x.
.y r,5 S ��� t.t 1 # I
Commonwealth of Massachusetts
Title 5 Official Insipect an Fora
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103 Drumoland Lane, Cummaquid
Property Address -. -- — — _
Paul Healy
Owner Owner's Name
information is 441 Warren Street, Needham'- �` MA 02492 October 27, 2010
required for every — _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert level with
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, a-hy
evidence of leakage into or out of box, etc.):
D-box was found in working order. `
ca
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.):
N/A
t .
Soil Absorption System (SAS) (locate on site plan, excavation,not required):
If SAS not located, explain why:
N/A
t5ins•09/08- Title 5 Official Inspection Form:Subsurface Sewage Dlsposal System Fags 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments.
103 Drurrioland Lane, Cumrriaquid Y
Property Address --- — --
Paul Healy_
Owner Owners --- --- ------
information is 441 Warren Street, Needham MA 02492 October 27 2010
required for every _ _ _
page. Cityrrown State Zip Code Date of Inspection
D. System Information. (cont.)
Type; a
® leaching pits number: 2 -4'X6'with 2' of
stone
❑ leaching chambers number'
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: . '
❑ overflow cesspool k number:
❑ innovative/alternative system``"
Type/name of technology:
Comments (note condition'of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil was sandy. Leach pit#1 was found:w' ith 6"of water present with a visible stain line approx. 2"
higher. Water level was low in pit#2.,No evidence of hydraulic failure'or problems in the past were
found at the time of inspection
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 N/A
Depth of solids layer N/A
Depth of scum layer N/A
N/A
Dimensions of cesspool ry
Materials of construction N/A
Indication of groundwater inflow ❑ .Yes 10 No
t5ins•09/08 Tide 5 Official Inspection Form Subaurlace Sewage oiai os syateiii Page 13 0l t 7
rat; 'i e-• ,y, t..
a i
ig
t;i 1 th l �1 t F
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103.Dru_moland Lane, Cumma 'uid__
Property Address --- —
Paul Heal
Owner Owner's Name --------- ------- — .information is 441 Warren Street, Needham MA D2492 October 27, 2010
required for every _ —
page. Cityrrown ; State „Zip Code Date of Inspection
D. System. Information (cone)
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
N/A
. - t
Privy(locate on site plan):
Materials of construction:. N/A
Dimensions - N/A µ
Depth h of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
e
J
t5ins•09l08 Title 5 Official Inspection Form:Subsurface Sewage Dispose!System Pape 14 of 17
+, i
Commonwealth of Massachusetts
W Titre 5 Official ;Ins e�ti®n F
p orm
Subsurface Sewage Disposal System Form - Not for Voluntary As
103 Drumoland Lane, Cum_maquid
Property Address -
Paul Healy
Owner Owner's Name —
information is
required for every 441 Warren Street, Needham MA 02492
page. City/Town — October 27, 2010
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
l Q, 13
I
32 ' S o
?s'
t5ins•09/08 �..
Title 5 Of ctal in
spection ectio n Form:Subsurface .;_.
Sawa a Dls. 9 .. posal S stem Pe
- ..Y. ._ .9e15of17,s
Commonwealth of Massachusetts
Title 5 official Inspection Fortin
A o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103 Drumoland Lane, Cummaquid
Property Address —— --
Paul Healy_ _
Owner Owner's Name
information is 441 Warren Street, Needham x' °MA 02492 _ ` October 27, 2010
required for every _ _
page. City/Town State Zip Code.. Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope �' r
❑ Surface water
® Check cellar .. .
Shallow wells
Estimated depth to high ground water: 14.01+
• 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: 7/17/85
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:
AIW 247 Zone C 22.9' 2.9' adjustment
You must describe how you established the high ground water elevation:
Test hole recorded on plan showed no water found at a depth of 13.0'. USGS groundwater map for
Barnstable shows groundwater to be approx. 48.5' below grade.,Groundwater adjustment at the time
of inspection was 2.9'. Bottom of leaching at 9.6' was found not to be located in the high groundwater
level at the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
j
t5ins•09/08 TIBo 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
Title 5 .Official Inspection Form
Subsurface Sewage Disposal System Form = Not for Voluntary Assessments
103 Drumoland Lane, Cummaquid
Property Address
Paul Healer t.
Owner Owner's Name — ---- — --
information is required for every 441 Warren Street, Needham MA _ 02492 October 27 2010
--
page. City/Town State - Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B. C, D, or'E checked x
® 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
y
t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 17
LOCATION SEWAGE, PERMIT NO.
VILLAGE
34 - o J
IHSTA LLER'S N4.ME 6 ADDRESS
12/z
OR OWN ER
�T d'/-��✓ �o sir
DATE PERMIT ISSUED '
.DATE COMPLIANCE. 'ISSWED �jli %�
a �a e
�o
No ..1./
103 THE
BOARD OF FHEALTH rs
f .l
�................OF. .............................._...-.._.
31I ............ .. ..
Appliration for Uh4paiial Vorkti Tumitrurtinn Prrmit
Application is hereby t}iad f�,a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at: L.c
..............3_ ...................................---C.... - --------------------------------------------------------------------------------------------------
Locatio Address r Lot No.y/ b
... . ._t. :::---... ... ------- �f --------- ----
Owner _•ess
YrvuG t��
a .............. ------- ........................ .._...._........--...........•------------------
Installer Address /y vOQ
el Type of Building Size Lot--...........,_.______._____Sq. feet
U Dwelling—No. of Bedrooms________________________________ _Expansion Attic (. ) Garbage Grinder ( )
Other—Type of Building __ ......... No. of persons.........3............... Showers Cafeteria ( )
Q' Other fixtures --------------------------------- -
W Design Flow......... 24-.........................gallons per person per day. Total daily flow....Z2 .__---___.____.__.___.____.gallons.
WSeptic Tank—Liquid capacity_/S-0.4?gallons Length................ Width................ Diameter---------------- Depth.................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-_---------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.....-..................................................................... Date........... �__�_7_:-_&Y
aTest Pit No. 1__ Q.......minutes per inch Depth of Test Pit....%.3_ ..... Depth to ground water........................
Test Pit No. 2... ......minutes per inch Depth of Test Pit....1.1__t"___. Depth to ground water------------------------
a' - - ......................................................................................
ODescription of Soil............ -------- Q.......... d...---'a')`?Sa -------------•-------------•-----•-----------------•-----------
x
--------------------------------------------=----------------------------------------------------------------------------------------------------------------------•-------------------••-•---••_------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:IT?";,;. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certi to of ompli s bee issued by oard oflaeal
e . �y . ��
Signed-- -- ----- ----•---••--------------- ....... --------------•- "------ --.�...y.._
Date
Application Approved By.......... - _ •--- -•-•----••••------
Date
Application Disapproved for the following reasons:.............................................................................................................
:
-------------•-----••--•-----------__-•--••-•-----------•-----...----------------••-.._......--•-----------•--------•---------•--------------------------------------------------------- ------------
Date
Permit No.--- .................. Issued......................................
Date
L _ �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...----.........oF:.. ?N f ..........................................
Appliraftan for Diipniial Works Tnnitrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................_................................................................................ ................................................_..._.......__..... - ..........
Location.Address or Lot No.
.......................-.......................................................................... ..........--......................................................................................
Owner Address
W
Installer Address
Type of Building. Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ,( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures ..................................
W Design Flow......,2.?--------------------------gallons per person per day. Total daily flow---- A..._..._.......__...........gallons.
WSeptic Tank—Liquid capacity/g'p.O gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter... .......... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.......................................
�4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •--••-••--- -----------•............--•••-•---••••--•••---•--••..................------•----•-•-•-•.....--•---•----•••...----••--•-••......-•---------••----
0 Description of Soil........................................................................................................................................................................
x
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 TITIL 5 of the State Sanitary Code_The undersigned further agrees not to place the system in
operation until a Certi sate of Compliance has beIdii issued board of he th.
Owe
g .-ne .. .•••• -• ............ ----••-•--••••• •--•-_..._..c3 q, )
i Date
Application Approved B ------} 6.�, _,,,, `� '
Date
Application Disapproved for the following reasons-----------------------------------------------------------•------•--------------•----------•••--•-----......•...
--••----------------•-----•--•----------•----•-......----•--•----•---------------------.............--•--'•----------------------•---------•----------------------------------------------------••-•-•---
Date
Permit -----------------. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................................................................................
�ntifiratr of TompliFanre
THIS IS TO Z
RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.......... � - - .....
Installer
has been installed in accordance with provisions of TI`11 5 of The State Sanitary Code
• � r as described in the
'
application for Disposal Works Construction Permit No.-&:._.P.of{.......... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NC, ION SATISFACTORY.
DATE--------------- -------/. . ........................................ Inspector------......---,---r---1---------------------------------------•........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ ......... .,0.s.V...........OF....... �f �s.�. aF'P.' Z................................ 7
°.�.
EE d.....
�i���a��al. nrk� �nn�#rUan rrnti�
Permission is hereby granted......f*-..CA..................V----------------•-----------•-••-••-----•----------------•--------•--........_................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No....... ?F f. .. �' ,
Street G'
as shown on the application for Disposal Works Construction Permit No._4S_..(tf._ Dated-- -2-- �� -------
Board of Health
DATE...• -
�AIA� f .<1.1k. ?.
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
tlwsssoland koad
Sop Sop Seat pit da. a*- S70 ,
�aedurrrc �° ;r„c 't5" wade 7-17-85 4 50 wide
seo Watet excoaate44d
:�
4.tonea a.torcea 'pe�cc. �ta-te 2 aus. pP.t l ' ,
a dia as !
.C'ot 11
ncediwa� �'
442 000 4,�.
sand nand: 1
74.9 No�V P- No Scate
U,
fitt o
I
49 /Doti 9ad
kyan� Ma,,. 0260/ d3.7
1500
Redation& ahow►t ate
based on an a&um" datua. \� \
0 .
P-topoaed
1500
t'
100170
1-6 '4 41 pit. I
;3 O W/2 1 4tone
204
pit
-392 ,d.
tP
° W2 'atone
Plan scate
Ir' a 40 , w
bate 11-12-8 S
Sketch Plan o4 Xand ld-.l9a4n&taUe, Na.
90ti eleit .Corti
gems lot I I as ahoon vn a plan of
fi"e L' and tiecotidddin'look 354 page 64•
-------A -- --- - -
ate: ��ze t occa-o�
°V.
OF
WILLIAM
v FARDIE N
+ A Q No. 8995
9o�FG15TEa����`� I
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