HomeMy WebLinkAbout0023 WESTCHESTER WAY - Health S
23,Westchester Way
Bamstable `
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No. V Fee h
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplitation for Disposal 6pstpm ConstCUttion 3permit
Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. .2 3 KI/?54 C,kk!s 2( W,4y Owner's Name,Address,and Tel.No. TohA HaTon 0 lsD
Assessor's Map/Parcel 106 1 &fo,5 4 ID
Installer's Name,Address,and Tel.No. A -4+CA --T Q>L.t.fno a Designer's Name,Address,and Tel.No.
M G-M T 2NX-
3a�fJ- Com�hcicc �arf= � S. C
Type of Building: Soft 4 3
Dwelling No.of Bedrooms p) 14� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) / kI T rLA t a r)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He th
Si d Date
Application Approved by Date 'A.
Application Disapproved by Nate
for the following reasons
r
Permit No. 'Z0( Date Issued 2
d
No. x Fee ho
r THE COMMONWEALTH OF MASSACHUSETTS Entered in co pater:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
i
01pplication for bisposar 6pstr.m Construction Vermit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 3 'tU es C Eu 54 P A y f Owner's Name,Address,and Tel.No. To h/1 4 Ma<<v n O 1 son
Assessor'sMap/Parcel �N ?l(a �,fo`S /0 1�c+.� !11,�`l-e J ✓ t
Installer's Name,Address,and Tel.No D r,v%d S Designer's Name,Address,and Tel.No.
3b?A Ca o c Pay !v f L a #
Type of Building: Sob Lt 3 a ov 0 3 '
Dwelling No.of Bedrooms �/►� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Pv y9a; 146 k t'rl Z �rl l Qyt
�.
=r Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation.until a Certificate of
Compliance has been issued by this Board�{of He Ith f 1
Sign d A , Date I Z
Application Approved by lM _ Date i
Application Disapproved by Date
for the following reasons J
Permit No. p( i Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned(i )by 'rtl
at 3 -� t�, � „�j�p has been constructed in accordance
rt°-
wKth l the provisions of Title 5 and the for Disposal System Construction Permit No. p 1 %� t dated (
Installer ; f Designer
#bedrooms_ Approved design flow gpd
r _
Thew-issuance of this perm' shall not be construed as a guarantee that the system iwillffunction`as(d signed.
Date Inspector
No. �� J � — � -/ Y Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS— '
Misposal *pstrm Construction J)ermit
Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permi
Date i Approved by L
i
E T1:
i
i
j
ComMonwealth of Massachusetts
uTitle 5 Official Inspection Form.
Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAYQ✓� �-
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
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. General Information
filling out forms
on the computer,
use only the tab . -
key to move your 1 Inspector:
cursor-do not David J. Burnie
use the return Name of Inspector
key.
David J. Burnie mgmt Inca
my Company Name
3 perry s way
Company Address
E. Harwich Ma. 02645
Ci /Town State Zip Code
tY P
1-866-980-1440 S1386
Telephone Number License Number
B. Certification
1 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 16.000).The system: A
❑ Passes Conditionally Passes ❑-Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/4/12
lhoWoRs Sign re � � .Date
The system in ector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 Official Inspection Foam S s rface Sewage Disposa Syst •Page 1 of.17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
, 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR.15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ® N ❑ ND (Explain below):
Septic System 1. Tank is leaking and needs to be repaired.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. CityrFown 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 M N ❑ ND (Explain below):
Septic system 1. Tank is leaking and needs to be repaired.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M °y 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
El 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 wateranalysis, 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
El ® 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 day flow
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments.
23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of.a surface water supply or
tributary to a surface water supply.
❑ ® -Any portion of a cesspool or privy is within a Zone 1 of a public well.
/
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates,absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A-copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact.the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes or"no"to each of the following; in addition to the
questions in Section D.
Yes No.
El ❑ 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
❑ Ell Area
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 Eor failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
b , 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ❑ Were as built plans'of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® Was the site inspected for signs of break out?
® ❑ Were all system,components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the.baffles or tees, material of construction, .
dimensions, depth;of liquid, depth of sludge and depth of scum?
® 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.
El Z 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): BHD own Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown
none BHD
t5ins+11/10 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is CUMMAQUID Ma 02637 7/4/12
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2011= 5.5 gpd
g ( Y 9 (gpd)): 2010= 16.4 gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.).-
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection '
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: None per BHD
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11110 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN & MARION.OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):.
Depth below grade: 36"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain).
Distance from.private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 101,
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
Septic system 1. Tank is leaking and needs to be repaired.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth: Tanks leaking can't get
measurement
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle Tanks leaking can't get
measurement
Scum thickness Tanks leaking can't get
measurement
Distance from top of scum to top of outlet tee or baffle Tanks leaking can't get
measurement
Distance from bottom of scum to bottom of outlet tee or baffle Tanks leaking can't get
measurement
How were dimensions determined? Tanks leaking can't get
measurement
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tanks leaking can't get measurement
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
.
page. Cityrrown State Zip Code Date of Inspection
D.. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ' ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm;level_: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 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
ti 23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10.BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is
required for every CUMMAQUID Ma 02637 7/4/12
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 oil
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 completely empty.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Located leaching pits with sewer camera. Both pits were empty of water.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. City/Town State Zip Code Date of Inspection
D. System 'Information (cont.)
Type:
z Teaching pits number: 2 @ 46
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ Teaching fields number, dimensions:
❑`. overflow cesspool number:
innovative/alternative s stem
ElY
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching pits were empty. Both leaching pits had water stains half way up,pits.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11110 Title 5Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Citylrown State Zip Code, Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
N , 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachuseft
Title 5 Official Inspection Fo ` C (
Subsurface Sewne D Sysftn Force,-I tot Voluntary Assessrnerft
OWM
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required for even �
stake code Data
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M-System Information (cord-)
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>1eet.Locate
where public water supply enters the building.Check one of the boxes below
❑ hand-sketch ip the area below
❑ drawing atta ed separately
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CS v
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15+/
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Lot elevation estimated 15'+/-above surrounding surface water within 500 yards. Bottom
of Leaching pits are 72", therefore the bottom of tank to ground water has a seperation of
You must describe how you established the high ground water elevation:
Lot elevation estimated 15'+/-above surrounding surface water within 500 yards. Bottom of Leaching
pits are 72", therefore the bottom of tank to ground water has a seperation of 7'10"+/-.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
E
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATEROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY �Gs;V►
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
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. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David J.Burnie
use the return Name of Inspector
key.
David J. Burnie mgmt Inc.
IC—V Company Name
3 perry's way
Company Address
E. Harwich Ma. 02645
Cityrrown State Zip Code
1-866-980-1440 S1386
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/4/12
Insp s igna a Date
The system inspector shall submit a copy of this inspection reportto the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
v .I �
t5ins•11/10 Title 5 111n OF.. Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON, 10 BAY-STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. CityrFown 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:
® 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:
System 2 is in normal working order.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system,.upon completion of the replacement or repair, as approved by
the Board of Health, will pass
Check the box for"yes", "no"or not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11110 Title 5 Official Inspection Form:Subsurface 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
, 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
® Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
,C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
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:
❑ ® 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.]
❑ E 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
❑ El the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241,
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑ '® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): Unknown
nkown - Number of bedrooms(actual): 2
BHD
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown
none BHD
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5 23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
'
page. CityrFown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2011= 5.5 gpd
9 ( Y 9 (gpd)): 2010= 16.4 gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
Commercial/Industrial flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official _Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
lug
23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is.
required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: None per BHD
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons .
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
-inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval
❑ Other(describe):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information ie CUMMAQUID Ma 02637 7/4/12
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate-on site plan):
Depth below grade: 37"feet
Material of construction:
❑ cast iron E 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Normal as to what we can see.
Septic Tank(locate on site plan):
9"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Septic system 2. Tank is in good condition
If tank is metal, list age:
year;
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
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
18"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
16"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Septic system 2. Tank had low water level.
Grease Trap`(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owners Name
information is required for every CUMMAQUID Ma 02637 7/4/12
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches,etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 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
, 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat:)
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 completely empty.
Pump Chamber(locate on site plan):
Pumps in working order. El Yes ❑ No
Alarms in working order: _' ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Located leaching pits with sewer camera. Both pits were empty of water.
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2 @ 46
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching pits were empty. Both leaching pits had water stains half way up pits.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert.
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts_
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON- 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is CUMMAQUID Ma' 02637
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information. (cont)
Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments.(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):, ,
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN &MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown 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
t5ins-11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth&fassachum fs
Title 5 Official Inspection Farm
Subsurface Sr a Dom!SVOm Rim-Not for Vourry As rents
i --
CMW i
WonnWanis
r+e*&W for emery '
Wrown A State zip Code iO of iron
D. System Information (corn.)
Sketch Of Sewage Disposal System:Provide a Wm of the sewage disposal system,including ties to
at Writ two pernwierd reference landmarks or benrthmarlm 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
t
ti
5•
•17l1D ry s 7as i Faut eih .S rt-�fsafff
...•� _,_' '. .f `. a..r.c^ a dlu9 � -A-. r: -' "G_....: 'Ym:t�'Y ..,..,- _ _ ._.,. "�...... _ -_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT,MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
i
® Check Slope
® Surface water
® Check'cellar
® Shallow wells
Estimated depth to high ground water: 15'+/
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
Lot elevation estimated 15'+/-above surrounding surface water within 500 yards. Bottom
of Leaching pits are 72", therefore the bottom of tank to ground water has a seperation of
You must describe how you established the high ground water elevation:
Lot elevation estimated 15'+/-above surrounding surface water within 500 yards. Bottom of Leaching
pits are 72", therefore the bottom of tank to ground water has a seperation of 7'10"+/-.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
-\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 WESTCHESTER WAY
Property Address
JOHN & MARION OLSON 10 BAY STATE ROAD, BELMONT, MA. 02478-2241
Owner Owner's Name
information is required for every CUMMAQUID Ma 02637 7/4/12
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
LOCATION P-- C; SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME&ADDRESS
2 0C2n
w► cr1
BUILDER OR O ?vER
I1 R.S d L,�O)\)
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
TO15
i
N TIP
o � �
ASSESSORS MAP N0-. Z_Z_9_
No. a PARCEL NO: OzLZ
...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di-lipwial Workii Tomilrurtion 11amit
Application is hereby made for a Permit to Construct or Repair (k✓�) an Individual Sewage Disposal
System at:
a-3Sn....... ........................................................... ......... ..... ...........-�oZ_ 7
Lo op-Address or Lot No.
W.......... ........................................... ---0�,44_11_4_A...fal_ ...........................................
Owner
Address
.........JR..... .............................................. .. ................................................................
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling— No. of Bedrooms.__--------_________________________________E xpansion Attic Garbage Grinder (A147
P4 Other—Type of Building ---------------------------- No. of persons___._.._-._-______-__--._._. Showers Cafeteria
Other fixtures -------------------------------------------
-- ----------------------------------------- -------------------------------------------------**----------Design Flow............................................gallons per person per day. Total daily flow-----------------------:....................gallons.
9 Septic Tank—Liquid capacity------------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. f t.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by....... .................................................................. Date--------.....---.....--------------.....
Test Pit No. I................minutes per inch Depth of Test Pit._..--_---_-__.___ Depth to ground water...__........._.........
f1 Test Pit No. 2................minutes per inch Depth of Test Pit..........._.._____. Depth to ground water_._.......:........._...
P4 .................. ..........................................................................................................................................
0 Description of Soil................................................................................................................................................................I.........
x .........................................................................................................................................................................................................
U
----------------------------------------------------------------- .......... --------------- -------------------------------------------------------------- .............
U Nature of Repairs Alterations—Answer when applicable.-A-7m...... ......................................9.-04
------------------- .. .........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been ued by t e board of health.
Signed ..........(fo�--------- W 0;�
----------------------- ------3......................:......
Application,Approved By -------------------------------- ........ ----------------1:e��-� '�-' —�? —
----- ..................... ---------------------------------------------- ----------------------------------------
Dwe
Application Disapproved for the following reaf ons: ------------------------------------/-------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- ----------------Permit No. -------------- --------------- - ---—---------- --------- Issued ------ !F�._— .......
Due
y ' No __� ................
THE COMMONWEALTH OF`MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Bi-nVn!3ttl Works Tomarnrtion ramit
Application is hereby made for a Permit to Constrict,( ) or Repair (r/) an Individual Sewage Disposal
System at:
........a�3. -WsT C-lA -------•--- 1 ` '
------------------- -
Loot o5�-Address or Lot No.
.....................................(J (r ................................. Al ao..........................................................
W f �Owner n h Address
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms.-_�__-__-_-_•___-__________________Expansion Attic ( ) Garbage Grinder (1,V
aOther—Type of Building ............................ No. of persons------------------------.--- Showers ( ) — Cafeteria ( )
al Other fixtures _____________________
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
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.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit_----------------- Depth to ground water-..._._.__.-_-_____-__
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit--------_----------- Depth to ground water----_...................
ixI ---•----------------------- --------------------------------------------•--•---•-•---------...---•••........................................................
0 Description of Soil.....................................................................................................--------------------------------------------------------------•---
x
V ------•-•---- ----------------•------•--•--•--•••••---._......-•-•--•----•-•-•---•-------•---•-----------•----•--...-----•----•---------------•-•-•---------•--------•••--•-----•......---•-----••-----
V. Nature of Repairs Alterations—Answer when applicable._A0.9...__ .'._.L� __r��. _.._ .... .�!....._.�.....D-_PCj
Agreement:
.The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
4, the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance hy, ued' by the board of health.
Signed ...... _.._......... 3`.. .�.c�-
-------------- ----- _
Application�Approved By �" 't. .. .� ... ^ -'. .....:..���-✓�
-------------- --- -- ------------
Date
Application Disapproved for the following rea.ronr: --------.......................... ------------------------------------....................-------------------.....---------
--------------------------------------------------------------------------- ------------------------------ ------------------------------------------------------------------------... ------ ........ ............
� a[e
Permit No. "' ''
Issued .... ...................... -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Ilertifirat e of C�omplinnce
THIS IS TO C FY, That t II dividual Sewage Disposal System constructed ( ) or Repaired ( ✓)
y c� L -
b ..._.... ........... ....... �....... G---------....-----....--------------- ---- ------------...-------_..---..---------.---.-------------------------------------- ........ ......... .........--------
It,.,tauet
......................................------------------------ ----------------------------------------- ../----------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITL of T e State Environmental Code as described in
the application for Disposal Works Construction Permit No. _ _. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ...... .. .6 _ ...r.�N�.. Inspector ----------- --- -- ---------------------_.----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 3a _
No............... FEE........................
trrt ion/OUvrhy GvPermission is hereby granted/ _
to Constr ct or Repair /a� Indiv al Sewage Disposal System
at No.. --3(•--- " / erutit
-
- -- -------------------
Strce ,t.``y� !� � r
as shown on the application for Disposal Works Construction Permi ______________ __Zted___�5_.__.- ,.._..C"4�._.
...••--..•--. . '...
. � -
. Board of Health
DATE. - �-
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS