HomeMy WebLinkAbout0040 FLINT ROCK ROAD - Health 40 FLINT ROCK RD., BARNSTABLEJ
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Commonwealth of Massachusetts
_ Title 5 official Inspection Form
4 Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
V
.,, . 40 Flint Rock Rd. `»
u _ -- —
Property Address
Katie Sastings
Owner Owner's Name / — - -- -
information is
required for every Barnstable V Ma. 02630 5-1-21
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 A. Inspector Information t
filling out forms
on the computer,
use only the tab Michael Sears _
key to move your Name of Inspector,
cursor-do not Jim The Inspector Man '
use the return Company Name
key.
P.O.Box 784
Company Address -
West Yarmouth
_ Ma. _ 02673 _
i
City/Town State Zip Code
�a 508-364-4398 -- S114430 ,
Telephone Number License Number
B. Certification „
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems,. After conducting this inspection I have determined
that the system:
1. ® Passes ��a►ululuna„
OF SAS 'i��'��
. S
2. ❑ Conditionally Passes
' MICHAEL
3. ❑ Needs Further Evaluation b the Local Approving Authority o SEARS
Y pp 9 Y U No.SI14430 Z
4. ❑ -FailseFRriF`�`��°�•0�
5-1-21
Inspector's Sign re Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
{ the buyer,,if applicable, and the approving authority,. .
Please note: This report only describes conditions at the time of inspection and under the,
conditions of use at that time.This inspection does not address how the system will perform§
in the future under the same or different conditions of use. .,
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
i
Commonwealth of Massachusetts „
Title 5 Official Inspection Dorm
1I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Flint Rock Rd.
Property Address .T r.
Katie Sastings a •
Owner Owner's Name _
information is Barnstable Ma. 02630 5-1-21 _
required for every �-
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2 3;or 5 and all of 4 and 6:
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 orin 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in working order
4 I • _
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. r
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):
----- ----- -=-- -
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Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments
/ 40 Flint Rock Rd.
Property Address i r
Katie Sastings -
Owner Owner's Name —information is Barnstable _ Ma. 02630 .5-1-21•
required for every �._
page. City/Town State Zip Code . Date of Inspection -
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or`breakout 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: F ❑ Y ❑ N ❑ ND (Explain below]'.
s , ,
❑ 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 -ayear 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: p
❑ Conditions exist which require further evaluation by the Board of Health in,order to'determine if
,the system is failing to protect,public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 ~
Commonwealth of Massachusetts
Title 5 official Inspection Form'..-
Subsurface Sewage Disposal System.Form --Not for Voluntary Assessments
!% 40 Flint Rock Rd.
Property Address - --
Katie Sastings r
Owner Owner's Name information is Barnstable Ma. 02630 _ 5-1-21
required for every ._ _ - =�` r _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary(cont.)
❑ Cesspool oNr 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 tan Kand SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS.and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other,failure criteria are triggered. A copy of the analysis must
be attached to this form. "
c. Other: i
n .
4) System Failure Criteria Applicable to All Systems:
You must'indicate "Yes" or"No"to each of the following for all inspections
tM Yes No ,
® Backup of sewage into facility or system component due to overloaded or.
clogged SAS or cesspool
- 0 ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/2 612 0 1 8 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18' -
3
Commonwealth of Massachusetts .
Title 5 Official Inspection Dorm
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Flint Rock Rd.
Property Address
Katie Sastings
Owner Owner's Name
information is Barnstable Ma. 02630 ' 5=1-21
required for every _
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary(cont.)
4) System Failure Criteria Applicable to All Systems: (cont.) ,
Yes No
❑ ® Static liquid level in the distribution box''above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(§). 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.
❑ ®4 Any portion of a'cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria,indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ®; The system is a cesspool serving a facility with a design flow of 2000 gpd- j
10,000 gpd.
❑ ® The system fails: I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
,system owner should contact the'Board of Health to determine what will be
necessary to correct the failure.
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 i
❑ ❑ the system'is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to Y ry a surface drinking water supply .
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
n
Commonwealth of Massachusetts
Title 5 Official In I� spection dorm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Flint Rock Rd.
Property Address
Katie Sastings
Owner Owner's Name r_
information is Barnstable Ma. 02630 5-1-21
required for every _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for a//inspections:
Yes No
r ,
® ❑ 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?
t
® ❑ '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)
® ❑F Was the facility or dwelling inspected for signs of sewage back up?
® ❑ - Was the site inspected for signs of break out?
® ❑ .Y Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank_
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ 'Existing information. For example,'a plan at the Board of Health.
❑. ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
f
c Commonwealth of Massachusetts
Title 5 Official' Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Flint Rock Rd.
Property Address `
Katie Sastings _
Owner Owner's Name
information is Barnstable r Ma. . 02630 5-1-21
required for every
page. CityfFown State • Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents:
Does residence have a garbage grinder?. ❑ Yes ® No
4
Does residence have a water treatment unit? - ❑• Yes ® No
If yes, discharges'to: =W
Is laundry on a separate sewage system? (Include laundry system Finspection
information in this report.) - ❑ Yes ® No
Laundry system inspected? [I, Yes ® No
Seasonal use? - s _ ❑ Yes ® 'No
Water meter read ings;•if-available (last 2 years usage (gpd)): ' 2019-67000 gal
.2020-52000 gal ,
Detail:
o
Sump pump? El Yes ® No
Last date of occupancy: Present
.a N Date
t5insp.doe-rev.7/2612018 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
40 Flint Rock Rd.
Property Address ;
Katie Sastings
Owner Owner's Name
information is Barnstable Ma. 02630 b-1-21
required for every __ - _
page.
City/Town h, State 'Zip Code Date of Inspection
D. System Information (cont.)'
2. Commercial/Industrial Flow Conditions:.',
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.; etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding•tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: -
Last date of occupancy/use: date
Other(describe below):
3. Pumping Records: °
Source of information: 2018
Was system pumped as part of the inspection? ❑ Yes ❑ No
.If yes, volume pumped:
gallons .
How was quantity pumped determined?
Reason for pumping:
- r
t5insp.doc 'rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Ins ection fornn.,
�a Subsurface Sewage Disposal System Form - Not for'Voluntary Assessments `.
40 Flint Rock Rd. x }
Property Address
Katie Sastings, P. e
: r
Owner Owner's Name
information is 02
bl t Barnsae Ma. , 630'; Y 5-1-21
required for every - - t _ k
page. Cttyfrown State Zip Code , 'Date of Inspection
D. System Information (cont )
,
4. Type of System:¢ f
® Septic tank, distribution box,•soiI absorption system;
❑, Single cesspool
` 4-
❑ Overflow cesspool;
f `• * ..dr' �5� y ,` fly' i. ....
❑.. ' ..
Privy:
_ s
u. Shared System(Yes or no)(if es,•attach Devious inspection records, if any),
❑ N 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 -
El Tight tank Attach a copy of the DEP,approval`,, `
❑ .E Other(describe): ,
Approximate age of all components, datefinstalled (if known)'and.sour'ce'of information:
7,
88-113-85 #86-227 s '�
1. : :
Were sewage odors detected when arriving at the site? ❑ Yet'®F No
.' T
5. Building Sewer(locate on site plan)
26„
Depth below grade:
feet -
Material of construction.
cast iron , - • ®40 PVC ❑-other(explain). —
° Distance from private water supply well or suctionµ brie a
feet 3 4� „
Comments (on='ndition of ioints,Nventing,°evidence of leakage,etc) 7- g -
F.
r
r :
Ak,
t5ins .doc•rev.7/2612018 ' 1`
p 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
40 Flint Rock Rd.
Property Address ,
Katie Sastings
Owner Owner's Name
information is Barnstable _Ma. 02630 __ 5-1-21.
required for every __ __ _ _ :.- _
page. Cityrrown State Zip Code Date of Inspection
D. System. Information (cont.) ,.
6. Septic Tank(locate on site plan):
/ r,• 5
Depth below grade: z feet —
Material of construction:o struction:
® concrete ❑ metal: ` ❑ fiberglass .^ ❑ polyethylene ❑ other(explain)
1000 gal
If tank is metal, list age:, years Y r
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate). ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth: 211,
`a
Distance from top of sludge to bottom of outlet tee or.baffle 28
Scum thickness° '
Distance from top of scum to top of outlet tee or baffle` 12
Distance from bottom of scum to bottom of outlet tee or baffle -
How were dimensions determined? Sludge judge tape plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 gal tank within and;out tees in place, inlet cover 6" below grade
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
t
Commonwealth of Massachusetts T .
Title 5 Official Inspection Form.,
IT h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Flint Rock Rd.
Property Address
Katie Sastings
Owner Owner's Name
information is Barnstable Ma. 02630 " 5-1=21
required for
9 4 every —
page. Cityrrown - State .Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Traplocate on site plan):
( p
t
Depth below grade: -
feet.,
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions: -
Scum thickness =--.
Distance from top of scum to topof outlet tee or baffle =
A
Distance from bottom of scum to bottom of outlet tee or baffle -- -
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): .
{
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate'on site plan):
Depth below grade:
Material of construction:
R
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
a
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
40 Flint Rock Rd. _
Property Address
Katie Sastings
Owner
Owner's Name
information is Barnstable Ma. 02630 5-1-21
required for every -.- -
page. CityTrown State Zip Code Date of Inspection
D. System Information,(coat:)
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.): y
t
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert a° 0
Comments(note if box is level and*distribution to outlets equal, any evidence of solids carryover,,any
evidence of leakage into or out of box, etc.): ,
D Box is 16x16 with 1 outlet pipe, cover at 24" below grade
t5insp.doc•rev.7126/2018 Title 5 Official Inspection.Foam:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official -inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments> '
40 Flint Rock Rd.
Property Address
Katie Sastin s _
9 _
Owner Owner's Name
information is Barnstable Ma. ' 02630 5-1-21
required for every - --
page. City/Town State Zip Code. Date of,Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan): b
Pumps in working order: ❑Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and"appurtenances, etc.):
* If pumps or alarms are not in.working order, system is a conditional pass.-
11. Soil Absorption System,(SAS) (locate.on,site plan, excavation not required):
If SAS not located, explain why:
Type
leaching'pits number: —
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ j leaching fields'. number, dimensions:
❑ overflow cesspool number: —
❑ ,, innovative/alternative system
Type/name of technology: -
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:rSubsurface Sewage Disposal System-Page 13 of 18 r
Commonwealth of Massachusetts
Title 5 official Inspection Form _
<1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
• 40 Flint Rock Rd.
22L ji
Property Address a '
Katie Sastings
Owner Owner's Name _
information is Barnstable Ma. r 02630 5-1-21
required for every _
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.) y ':
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is a 1000 gal pit, Pit is clean.with 1'of standing water and no sign of failure
F
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration f
Depth=top of liquid to inlet invert.; `
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction a -
Indication of groundwater inflow £ • ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
f
Commonwealth of Massachusetts '
Title 5 official Inspection F®rm,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Flint Rock Rd. '
Property Address v `
Katie Sastings
Owner Owner's Name
information is required for every Barnstable Ma. 02630. 5-1-21.
_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) `
13. Privy (locate on site plan):
Materials of construction: rt"
Dimensions £'
Depth of solids -=-- =
Comments (note condition of soil, signs of hydraulic failure, level of ponding„condition of vegetation,
etc.):
4.'
4.
l5insp.doe•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
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
40 Flint Rock Rd. _
Property Address
Katie Sastings
Owner — _..
Owner's Name .
information is Barnstable_ Ma 02630 5-1-21
required for every - � '
Clt !town
State_- .. - ----- —-.... .... --- ._—.---- --
page. y Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:`
Provide a view of the sewage disposal system, including ties to at least.two permanent reference
landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below;-'
® hand-sketch in the area below
❑ drawing attached separately
a
S
' 1 e r s.-
e F 1 X.
a r
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
t _
P
Commonwealth of Massachusetts
. .:.
I Title 5 official Inspection Form
�n is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. � 40 Flint Rock Rd.
Property Address
Katie Sastings _
Owner — -- ——
Owner's Name
information is Barnstable Ma: 02630 5-1-21
required for every ---_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) A
15. Site Exam:
t
® Check Slope
® Surface water ,
x ,
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10+ — --
il feet
Please indicate all methods used to determine the high ground water elevation:
P
® Obtained from system design plans on record
y
If checked, date of design plan reviewed: April 1986
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:
No ground water per plan'
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Flint Rock Rd.
Property Address
Katie Sastings
Owner Owner's Name
information is Barnstable Ma. 02630. 5-1-21
required for every ---
page: City/Town r 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,4
1, 2, 3, or 5 completed as appropriate 7
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
1 F
01 As
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 or 18
p .
4/22/2021 ShowAsbuilt(1700X2800)
LOCATION SEWAGE PERMIT NO.
YI ILAGE•
INSTALLER'S NAME 9 ADDRESS
U I L 0 1 R OR OWNER
i/i/���A S f7/r7 HG'•'S i
DATE PERMIT ISSUED y �G
DATE 'COMPLIANCE ISSUED
,3
3y �
https://itsgldb,town.barnstable.ma.us:8431/Home/ShowAsbui It?mp=316080002&sq=1 1/1
Commonwealth of Massachusetts Eko-080--00 7—
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments a
°w 40 Flintrock.Road r
M
Property Address
Joanne &Jeff Hastings '
Owner Owner's Name
information is u
required for every Barnstable MA 02630 01/09/2018
page. City/Town State Zip Code Date of Inspection ei
Inspection resultsmust be submitted on this form. Inspection forms may not.'be altered P•.i1n any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Mike DeCosta Jr.
use the return key. Name of Inspector
Wind River Environmental
r� Company Name
46 Lizotte Drive Suite 1000
Company Address
Marlborough MA 01752
City/Town State Zip Code
800-499-1682 SI 13230
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,.accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal.systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:,
0 Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
l � 01-09-2018
Inspector's Si ature bate
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 DER 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 offninspection and under the conditions of use
at that time. This inspection does not address how the system will perform in`the future under
the same or different conditions of`use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 40 Flintrock Road
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 9 02630 01/09/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete'all of Section D
A) System Passes: A
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inlet cover 12"BG. A riser and filter will.be installed on outlet cover as part of inspection.
B) System.Conditionally Passes:
❑ One ormore 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.
ry
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):
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspectior! Fora
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 40 Flintrock Road
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 02630 01/09/2018
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont,):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to,a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health);
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
The m required
❑ system e u ed pumping more than 4 times.a year due to broken or obstructedpipe(s).The
Y q P P 9 Y
system,will pass inspection,if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning,ir a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
40 Flintrock Road
M "
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 02630- 01/09/2018
page. City/Town :State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in-a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet!but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following,for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface`of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 official 'Inspection Form
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
°M 40 Flintrock Road
Property Address
Joanne &Jeff Hastings,'
Owner Owner's Name
information is required for every Barnstable MA 02630 01/09/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
�- Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of.a cesspool or privy is within a Zone 1 of a public well.
® Any.portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. .
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes- No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question,in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or'operator of any large
system considered a significant threat under Section E or failed.u rider.Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 Flintrock Road
Property Address _T
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 02630 01/09/2018
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
❑ N 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?
El ® 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 systemcomponents,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?
® El Was the facility owner(and occupants if different from.owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the•Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 1-10 gpd x#of bedrooms): 330 GPD
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form p
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 40 Flintrock Road
Property Address
Joanne Jeff Hastings
Joa e &Je
_
Owner Owner's Name
information is 4
required for every Barnstable MA 02630 01/09/2018
page. Cityrrown State. Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection= ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes Z No
Seasonal use? ❑ Yes ® No
Water meter readin s, if available last 2 ears usage 3Z0 GPD
9 ( Y g (gpd))�
Detail:
See attached records.
Sump pump? ❑ Yes ® No
Last date of occupancy: Summer only
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank.present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 40 Flintrock Road
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 02630 01/09/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: The home owner and Wind River Environmental are
the sources of the information.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,000gallons
t - 4.
How was quantity pumped determined? The quantity was determined by the pump truck and it
was measured.
Reason for pumping: To check the structural integrity of the septic tank.
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.
El Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts.
w Title 5 Official Inspection Forma
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y
40 Flintrock Road
Property Address
Joanne&Jeff Hastings_
Owner Owner's Name
information is required for every Barnstable ,` MA 02630 01/09/2018
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:
1986 per plans.
Were sewage odors detected when arriving at the site? ❑ Yes Z. No
Building Sewer(locate on site plan):
Depth below grade: 2 N
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or f
suction line: eet
feet
Comments (on condition-of joints; venting, evidence of leakage, etc.):
All joints sealed. No leaks. Vent on roof. °
Septic Tank(locate on site plan):
Depth below grade: 18'
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
8'x5'x4'
Dimensions:
411
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .
,M 40 Flintrock Road
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 62630 01/09/2018
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
36
Scum thickness
4"
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? The dimensions were determined
by sludge judge, rod, and ruler.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both covers 18"BG. Tees in good condition, no filter installed on outlet. Liquid level normal,
moderate solids and sludge. Tank appears to be structurally sound, not leaking. A riser and filter will
be installed on outlet cover as part of inspection. Recommend pumping tank and cleaning filter
annually.
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 o'r baffle
1
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts '
W Title 5 Officia`I .Inspection Form.,,
Subsurface Sewage.Disposal System Form -' Not for,Voluntary Assessments
40 Flintrock Road "
Property Address
Joanne &Jeff Hastings
-
Owner Owner's Name
information is Barnstable MA 02630 01/09/2018
required for every '
page, City/Town State Zip Code Date of Inspection
D. System,Information (cony)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,istructural integrity;
liquid levels as related to outlet invert, evidence of leakage, etc.
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ .Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.)`.
*Attach-copy of current pumping contract.(re quired), Is copy,attached? ❑ 'Yes ElNo.
X
t5ins.doc-rev.6/16 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 40 Flintrock Road
Property Address
Joanne&Jeff Hastings
Owner Owner's Name
information is required for every Barnstable P MA 02630 01/09/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ; f
Distribution Box(if present must be opened)(locate on site plan):
011
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.):
Distribution box is 2'13G, box size 16"x20". Distribution box has one'outlet. Liquid level normal,
minimal carryover into box. Distribution box is in good structural condition,.water tight,not leaking.
Pump Chamber(locate on site plan):
Pumps in working order: ° ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site"plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage DisposaIr System Form -Not for Voluntary Assessments
M 40 Flintrock Road
Property Address -
Joanne &Jeff Hastings "y;
Owner Owner's Name
information is Barnstable MA 02630 01/09/2018
required for every _ "" _
page. CltylTown State Zip Code Date of Inspection
D. System Information (cont),
Type: s
leachingits number:
P 1 6'x6'
❑ leach ing:chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of -
vegetation, etc.):
Pit is on riser, cover 12"BG. Pit has over 3';of available space. Pit shows no signs of high stains. No
signs of hydraulic failure. Vegetation normal.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official' Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 40 Flintrock Road
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 02630 01/09/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) AI
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 ® icial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
A 40 Flintrock Road
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 02630 01/09/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks-or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below: -
❑ hand-sketch in the area below
Z drawing attached separately
A
t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
^M 40 Flintrock Road
Property Address
Joanne &Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA. 02630 01/09/2018
page. City/Town State Zip Code Date of,Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
Z Shallow wells
Estimated depth to high ground water: 10+
feet ,
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: April 1986`
Date
❑ Observed site(abutting property/observation hole within"I 50 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 groundwater elevation:
Obtained from copy of plans on file at BOH. .
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 " Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°M 40 Flintrock Road
Property Address .
Joanne&Jeff Hastings
Owner Owner's Name
information is required for every Barnstable MA 02630 01/09/2018
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary:A., B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System information— Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
AsBuilt Page 1 of 2
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LOCATION _ SEWAGE ' PERMIT NO.
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=316080002&seq=2 1/2/2018
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
—TRUDY COXE
w Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .F
PART A.
CERTIFICATION
Property Address: 40 Flint Rock Road, Barnstable, MA, Name of Owner: Nancy Lovely
Address of Owner: 77Sears Road
Date of Inspection: August 25, 2000 Wayland, MA 01778
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title'5`(310 CMR 15.000) r ,
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map:316
Telephone Number: (508)862-9400 Parcel:080
CERTIFICATION STATEMENT m"
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
Conditionally Passes
Needs Further Eval ti n By the Local Approving Authority
'Is
Inspector's Signature: Date: August 28,'2000
,
The System Inspector shall submit 5copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the'
system owner and copies sent to the buyer, if applicable,and the approving authority.
NOTES AND COMMENTS i
+.'�
V R e �•� 11 R� ' .f G.. g t A ,� .�0+. OO �f�•4'
A
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revised 9/2/981t' - :_ • Page 1of11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 40 Flint Rock Road, Barnstable, MA
Owner: Nancy Lovely `
Date of Inspection: August 25, 2000
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal,is cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a.complying septic tank as
approved by the Board of Health..
` Sewage backup or breakout or high static water level observed in the distribution box s;due to.broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system,will,pass,inspection if(with approval of the Board of
Healthj
broken pipe(s)ace replaced
' obstruction is removed
r -
distribution box is levelled or replaced
The system required pumping more than four 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
obstruction is removed
revised 9/2/98 Page 2of11
-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'`FORM
PART A
CERTIFICATION (continued)
Property Address: 40 Flim Rock Road, Barnstable, MA ', " .,.:� b d a"
Owner: Nancy Lovely ;r ' z: c: i„.•;±
Date of Inspection: August 25, 2000 :! r r"
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 the
public health, safety and 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 WHICHWILL PROTECT THE PUBLIC HEALTH AND
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.
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 T.HE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
V"The-system has aseptic tank and:soil absorption system.(SAS A; the SAS is within 100 feet to.-a surface water supply or
tributary to a surface water'Sllpply, .:f' 'Jlr.e�Sv 1;i.-L a7 f3€`1 ties ?':3 .1
_ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public,water supply well.
The system has a septic tank and soil absorption system and the SAS is withiw50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS.is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER a
a
revised 9/2/98 Page 3ofli
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 40 Flint Rock Road, Barnstable, MA . ... ._ s ..: .., .;, ., .;.,.• , . _,. . . ,_.
Owner: Nancy Lovely
Date of Inspection: August 25, 2000 "'."'a" _ .. .;?
D. SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
_ I have determined that one:or'more of the following failure conditions exist as described in.310 CMR 15.303. The basis for this ,
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow.
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 Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply:
Any portion ofa cesspool or privy is within.a Zone 1 of a public,well yt,.
- ...�i,.� .•i . ., ., ? � .tra r.. t is ._. ' �.� ;: .:l: .. ., .... r_ .
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has-been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is.a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM
PART B
CHECKLIST
Property Address: 40 Flint Rock Road, Barnstable, MA
Owner: Nancy Lovely
Date of Inspection: August 25, 2000
Check if the following have bee done: You must indicate either"Yes"or"No":`as to each of,the following:,. I1
�.
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built,plans have beeri'obtained and examined. Note-if they are nct available with N/A.. �
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
.y
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
or tees,material of construction,-dimensions;depth,of liquid-depth.of sludge;••depth.of scum.. } +}
The size and location of the Soil Absorption System on the site has been determined based on:
✓ Existing information. For example,Plan at B.O.H.
71
✓ _ Determined in the.fieldd(if any of the failure_criteria related to Part C.is at issue,,approximation of distance'is unacceptable)
[15.302(3)(b)l• r u..,•. x, ,
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
-
' .t., T'•`z! . J i - , r F:• y .i,l'. .,.L:' ik- e.'�[1. {i �. :'�.`
n
revised 9/2/98 Nge5of11
i.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ..
Property Address: 40 Flint Rock Road, Barnstable, MA ? �°
Owner: Nancy Lovely
Date of Inspection: August 25, 2000 :c:, , , ,; .;� . •:�:.
FLOW CONDITIONS ".
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no):No; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): 1999-88 000 pals.: 1998- 72,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gad(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no) f
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION .
PUMPING RECORDS and source of information:
Purmed on Nov 9198-per treatment plant.
System pumped as part of inspection(yes or no): No
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
_ Shared system(yes or no) (if yes,attach previous inspection records,if any)
UA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other;
iPPRO%IMATE A'GE•of all components;date installed(if known)and source of information: . 4110186 -per as built card —
Sewage odors detected when arriving at the site: (yes or no) No -
revised 9/2/98 Page 6of11
, Y C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION _(continued)
Property Address: 40 Flint Rock Road, Barnstable, MA 1 •f ,,tl;�,,a,,,�, :Y;,;aa.i h v-,t ':i r,- t,; Yu/ t ri. t, `a
Owner: Nancy Lovely
Date of Inspection: August 25, 2000 `;; � frlt;aE:°°. #plf, la:<tc. trti
BUILDING SEWER:
(Locate on site plan) ,
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)' a
Distance from private water supply well or suction line "
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 12"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other,(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) r
Dimensions: 10001;al.
Sludge depth: I" r
Distance from top of sludge to bottom of outlet tee or baffle: 30"
-- Scum thickness:_ 2
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How dimensions were determined: Measuring sticko
1
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) The baffle and tee were present The liquid level was even with the outlet invert. There were no signs of leakage.
The scum and sludge were minimal
GREASE TRAP: None
(locate on site plan)
Depth below grade:
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 s
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,,structural integrity,
evidence of leakage,etc.) -
revised 9/2/98 Page e 7 of 11
t 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: 40 Flint Rock Road, Barnstable, MA 7, r
Owner: Nancy Lovely
Date of Inspection: August 25, 2000
TIGHT OR HOLDING TANK: None'{Tank must be pumped prior to,or at time,.of-inspection),..
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓ - ": Er
(locate on site plan)
Depth of liquid level above outlet invert: --
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
The D box was located but not dug up There were no signs of failure in the pit
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address: 40 Flint Rock Road, Barnstable, MA
Owner: Nancy Lovely
Date of Inspection: August 25, 2000
t.�"}rl3. «�'.3 15. i;;4i, 1371 T•I z �:
SOIL ABSORPTION SYSTEM (SAS): ✓
(locate on site plan, if possible; excavation require
If may be approximated,by non-intrusive-methods), ;;•,-
If not located,explain:
Type:
leaching pits, number: 1-6'x 6'
leaching chambers,number:
leaching galleries,number: ,
leaching trenches,number, length:
leaching fields, number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation;etc.)
The pit had 4'of water on the bottom. The scum line was at the same level. There were no signs of failure. The bottom of the pit to grade was
approximately 8'6".
CESSPOOLS: None
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: ' s `t'° ~'�;31 '.• r�;c l:r+�..e
Depth of scum layer:
p.
Dimensions of cesspool: a..
Materials of construction:
Indication of groundwater: -
inflow(cesspool must be pumped as part of inspection).
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
PRIVY: None
(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.)
revised 9/2/98 y ' Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,,(continued)
Property Address: 40 Flint Rock Road, Barnstable, MA
Owner: Nancy Lovely
Date of Inspection: August 25, 2000
Map:316
Parcel.080
:1
SKETCH OF.SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water•supply comes into house)
4A�k
A Q
«k
02 Al , .
(3 1 - aq
3 AA- 3(0
13a- 39
y
AS- 90
f33' 319
Ay - 3o
revised 9/2/98 Page 10ofli
„
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONS FORM
PART C
SYSTEM INFORMATION (continued),
Property Address: 40 Flint Rock Road, Barnstable, AM w. 3
e`.i:;:. �'C•'�3",+'e. +2'6 ,�.,�i7
Owner: Nancy Lovely
Date of Inspection: August 25, 2000
NRCS Report name
Soil Type
Typical depth to groundwater `
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar p
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
a
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps ;
Checked pumping records
Check local excavators, installers
✓ Used USGS Data ”
Describe how you established the High Groundwater Elevation. (Must be completed)
The bottom of the pit to grade was approximately 8'6". Using the Barnstable topographic map and water contours map, the maps
were showing approximately 55' +/-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high
groundwater adjustment for this site(AIW 247 Zone B, 7/00)was 4.6'.
r
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
LOCATION _ SEWAGE PERMIT NO.
4e 7- Z
VILLAGE
I N S T A LLER'S NA {RE A ADDRESS
C
z/,.4 ,u ,�s�,r✓ 41
D U I L D E R OR OWNER
a
DATE PERMIT ISSUED :11Z7�d6
DATE COMPLIANCE ISSUED !a 9
1
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No_cd6_zZ 5
` 3 THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..........;7r /?.........OF.............:°�__ 2��s� 4 9...................
Appliration' for Ehiivos al Works Tomtrurtion Prrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
.............. ......�.1...... .._.... /OJ T- ..._.....-----.......................---
• cation-Ad ress or t `
._-. ...... :��.
.........
Owner Addr
�U/�7
PQ Installer r Address
Type of Building Size Lot___f"� __Sq. feet
aDwelling—No. of Bedrooms.................................._______...Expansion Attic ( ) Garbage Grinder ( )
p4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures _________________________________ _
-----•-----------
W Design Flow____________________________________________gallons per person per day. Total daily flow.................
WSeptic Tank—Liquid capacity/ .-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.
Other Distribution box ( ) Dosing tank ( )
�" Percolation Test Results Performed by.........................____f�2.� Date........
,aa Test Pit No. 1.167� _minutes per inch Depth of Test Pit____________________ Depth to ground water........................
fz, Test Pit No. 2 r_!'_minutes per inch Depth of Test Pit____________________ Depth to ground water........................
-----------------------------••------•--- .......
O Description of Soil.......................................... ......-• !l� :
V ----------------------------- ----•----------•---------------------------------------------------------------------------------------------
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 iIHE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ,
operation until a Certificate of Compliance has been issued by the bo r o I th.•
igned.............. -•--• ........ . -•-- • ---•• -- -•••--•-• ......
` Date
Application Approved By.......................
. .. ......... .. . ..... -----•---•-•--•-- ---•---
Date
Application Disapproved for the follow g reasons-------------------------------------•-------•---•-• ...........................................................
---------------------------•---------......--.--...---------------------•-•-----------------•-------•---------••-----•------•-•-••••-----
Date
PermitNo......................................................... IssuedL.............................................
y
rr i
P"
No.. 26L 2- RO..............................
..........
' . 7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-10;/V.........OF............ .............
- - --- ---------
Appliration for Disposal Works Toustrurtion Prrmit
'Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
L,07
......... <5)
................. .............0........................................................ ...........................................4Z..•--:................
A I
-Location-A Xk— or Lot No.
/A/ ........ ............ P, &,), ".. �,............. .......................1�7------------------7,t�Tfs,...... ...........
Owner Add5k,;�
...................................0.......................................66 IV
Installer Address
Type of Building
Size Lot.__
�le� Sq. feet
U
�4 "2 7.
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
PLO Other—Type of Building ............................ No. of persons--------------------------- Showers, Cafeteria ( )
Otherfixtures ...............--------------------------------------------------------------------------------------0.... . ... . . .......................
Design Flow............................................gallons per person per day. Total daily flow................ ...........gallons.
9 Septic Tank—Liquid capacity./('ID.gallons Length................ Width-_-_-_-________- Diameter-_.-___-_______- Depth.........._.....
Disposal Trench—No. .................... Width.................... Total Length........._.......... Total leaching area....................sq. f t.
Seepage Pit No..................... Diameter....___..._....._... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank ( ) -7 —
.... .... 14 Dai .....
Percolation Test Results Performed by.................. ................. te
1-.4 7
Test Pit No. I--- 5..minutes per inch Depth of Test Pit.................... Depth to ground water.......__._.............
44 Test Pit No. 2,,y'V9-1,0'_minutes per inch Depth of Test Pit.................... Depth to ground water........................
y
P4 .............................................................:-............ ...............
0 ......._e--------**---------------------*-------
Description of Soil.................................... ......
--------------------------------------------------------------------------
.......................................................................................................................................... .........................................................
.................................................................................................................................................................................................0......
U Nature of Repairs or Alterations—Answer when applicable....,...........................................................................................
............................0...................................................................0................... ...................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with
the provisions of'.LI" 'PIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
,
operation until a Certificate of Compliance has been issued by the bdalrd-o-f'lilebb th.
§igRed..................... .......... a_:...... . .......... ....... --------
late
Application Approved By....................... 4V_%S0...... . ...... ........... fDate
Application Disapproved for t ego reasons:............................0.................................................................................
.................................................................0.......................................................................................................................................
Date
L .......................................
Permit No...................................................... Issued ............. .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
W T rtifiratr of T W11 utpliatur
r
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,J) or Repaired
b ........................o.......... ..... ..................................... ..............................................................
y .... .....
,jnsta.ler
.......... ................................................
at............
has been instilled in accordance with the provisions of TITLE 5 of The State Sanitary Code as dFscribed in the
applicatio'h4or Disposal Works Construction Permit No.__-_- _-i..-.7.......... dated----------sfuq/---q4.................
"k, THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
0/
DATE....................................7/..f.A.j...X..................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... 0 F..........e 6.....f--
..................
No......................... FEE_............... .....
Disposal Works T-511nstrudion "rrufit
Permission is hereby granted.............L<J.. IIAAI ek---------VAC _Xsjx. ..............................................................
to Construct or Repair an Individual, Sewage Disposal Syste'in
L .......
. .........
at No.............. ....... ---------4,11-----------VS
Street
o? -7 Dated ..... ...... ....
as-shown qn.,theapplication for Disposal Works Construction Permit N ..........F.1...... 7Z 31 14 ............
...............I..............................I- -------—
of
c, alth
DATE---------------.... .7 1........................ Bo
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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69
LEGEND R�p�
EXISTING 5POT ELEVATION. OxU ,."> CERTIFIED VPLQ:T. PLAN
EXISTING CONTOUR`-- p - - L0 r rz, "/T°
1NISHED SPOT ELEVATION y
= NISHED CONTOUR 0 IN
I,PPROVED a BOARD- OF.:HEALTH `•.^
DATE AGENT / ,� No SCALE l " =.4Q DATE.S.'/ /�f �
'LD RED GE ENGINEERING CO. IN /V/cxv�Ns
CLIENT I CERTIFY THAT THE—' PROPOSED#
EGISTERE REGISTERED �9So 9y
JOB NO. BUILDING ' SHOWN ON •THIS Pc AN
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