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HomeMy WebLinkAbout0039 MUSKEGET LANE - Health 39 Muskeget Lane Centerville U A = j No.42101/3 ORA 10°l0 `O( © o 0 0 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s.. 39 Muskeget Lane "�� Property Addressu+ Steven Money Owner Owner's Name information is required for every Centerville Ma 02632 2-7-19 page. City/Town State Zip Code Date of Inspection fi l 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 c51# 135 filling out forms -I on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 c� Company Address Sandwich Ma 02563 City/Town State Zip Code r (508)477-0653 S113747 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. FMI Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board • of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— ' 39 Muskeget Lane Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 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 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Ial Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .v 39 Muskeget Lane Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 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 break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane u Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) I ❑ Cesspoolis within 50 feet of a surface water or privy Y ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ O Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane u Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 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 all inspections: Yes No ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ 0 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? O ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muske et Lane Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/gpd Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes El No information in this report.) Laundry system inspected? ❑ Yes RI No Seasonaluse? ❑ Yes [E No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2018- 13,000gallons 2017- 24,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: 9/2018Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane v Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes M No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 39 Muskeget Lane �V Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2-11-02 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 116" Depth below grade: feet Material of construction: ❑o 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 1 Dimensions: 500gallons 611 Sludge depth: 3019 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 6„ Distance from top of scum to top of outlet tee or baffle 1411 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane V Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form °I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane u Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane Property Address Steven Money Owner Owners Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes No* Alarms in working order: ❑ Yes No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * 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: (3)500 gallon chambers leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form ,m le Subsurface Sewage Disposal System Form Not for Voluntary Assessments 39 Muskeget Lane �u= Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in passing condition. The chambers were dry when viewed with no sign of past backup. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 . c , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I tJ 39 Muskeget Lane Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.726=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane L Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately �rt3wrt of a,+►xN�'rxs� � ; Lacerrox _ sk a"T 1"i:ar.r. vwcEr. n42- ��F Vus.wvr. C .srti'E' u ► wsseMn's iawrs LOT u rsrw ,s N ?Ron Ko �`�" .dt1���',r�1&eti tw,v.✓ .,- sHmc,:TAz4K wAcrrY l.r- 6 LRACtertta`PACMrr r tgIo6)1""itDA Bt dMER;OR OWNER *6*4 sJ PBRMrrVA'YE__!?�l` �2 C+CiMPf:I%41VG"EDllCf!: //+�d� sapiral3ota:Tils4nce t3etweea ttte 'T7 Maid AA Wited Ci�titadwxtsrZ�bt a toihe Hittom nt~L,smt44 F*dt#y I P varos Wxftrt'tt4*Y WeU anc!"I eacli Facility tY any waii,"eanst �>tliic or a!idiie 200,feet taf lattdsiny{tadiily} _: Rest I:tiQie of Wmtlaad a»d Y;eerkdag"Yttic�sy Ctta�ny wataaifds eiift r+nlLln�9U0-feptofteaet±in6'•taci�itl"r1, Feat F�hadby , + ,la:titJ"x ie4a t � f t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '- I;l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane v Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑■ Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 138"feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 12-4-01 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts +� Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Muskeget Lane V� Property Address Steven Money Owner Owner's Name information is Centerville Ma 02632 2-7-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed D. System Information: I For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNS TABLE L LOCATION 3 9 A4 uske G e �L.f�,l/2 SEWAGE # :0V2- 7 L/f VILLAGE C eA1 f e R V/L L ,e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. _T p A4 `4 C CO A 8 eK SEPTIC TANK CAPACITY /..f Q O LEACHING FACILITY: (type)3 " 4DA y ai L ZL'S (size) 3.3 4f'-r f,� NO. OF BEDROOMS y BUILDER OR OWNER MC. i PERMITDATE: 1 Z I`/ C COMPLIANCE DATE: 2///Al a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 4 t1� vS`kp���` :% _� � , ���� . t , . � � i � � f_ i � �. � �, �� f i No. Fee $5 0.0 O ` ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for ;Diopaal Opgtem Cottgtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 92 Complete System O Individual Components Location Address or Lot No.39 Muskeget Lane Owner's Name,Address and Tel.No. Maxwell Money Centerville,Mass.02632 39 Muskeget Lane Assessor's Map/Parcel 00 5' Centerville,Mass.02632 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—9 7 0 O J.P.Macomber & Son Inc. Ronald J. Cadillac,PLS,RS Box 66 Centerville,Mass.02632 P.O.Box 258 W.Y.Mass.02673 Type of Building: DwellingXX No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil See Plan Nature of Repairs or Alterations(Answer when applicable) Installing 1 -1 500 gallon septic tank, 1 -rIi _t-ri hiati nn hnx and 3-500 gallon leaching chambers packed in 4 ' of 1�1 " stone_ Pump fill n the existing cesspools. 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 Certifi- cate of Compliance has been issu9d by thi o d "th. Signed ``r Date 1 2/1 1 /g 1 Application Approved b '7 i Date Application Disapproved or the following reasons Permit No. 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(XX)T Abandoned( )byJ.P.Macomber & Son Inc at 39 Muskeget Lane Centerville Mass. b 11e: constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer J.P.Macomber & Son Inc. DesignerRona J. C i lac,PL$,RS y The issuanc of this permit shall not be construed as a guarantee that the syste�tnWill.function as de i ned. Date 7 Inspector 1/ 41 ' ------------------------— ----- -- - No. Fee$ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migozal *pgtem (Construction Permit Permission is hereby granted to Construct( )Repair(X�Upgrade( )Abandon( ) Systemlocatedat 39 Muskeget Lane CEnterville,Mass. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons tru t m t be co pleted within three years of the date of t e Date: � Approved by ! (/ ! $50 No. * ` .,. Fee 00 Entered in computer: v THE COMMONWEALTH OF MASSACHUSETTS Yes µ-f - PUBLIC`HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for ;Mio pool bpgtem Construction Permit Application for a Permit to Construct( . )Rep*( . )Upgrade( )Abandon( ) X Complete System O Individual Components Location Addressor LotNo.39 Muskeget Lane Owner's Name,Address and Tel.No. Maxwell Money Centerville,Mass.02632 39 Muskeget Lane Ass essor'sMap/Parcel A Centerville,Mass.02632 Installer's Name,Address,and Tel.No. A0 8-7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—9 7 0 0 J.P.Macomber & Son Inc. Ronald J. Cadillac,PLS,RS Box 66 Centerville,Mass.02632 P.O.Box 258 W.Y.Mass.02673 Type of Building: DwellingXX No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons.`' Plan Date """k - Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil See Plan Nature of Repairs or Alterations(Answer when applicable) Installing 1-1500 dallon septic tank,l-distribution box and 3-500 gallon leaching chambers packed in 4 ' of 13" stone. Pump fill in the existing cesspools. Datelast 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 Certifi- cate of Compliance has been iss dd by this o 'd f edlth. Signed �4 j Date 12/1 1 /01 Application Approved by Date Application Disapproved or the following reasons v ,�- n T Date Issued Sep-14-01 08:07_6 NS"rABLE HEALTH DEPT 508790630,4 � p.OZ ��ZSm 1 NOTICE. This Form Is T � - 1 BeI3c Use t �; h� Repair �._ air p Ot 1 a;!IEd � Septic Systems Only. PERCOLATION ,r_ ST :�N_D SOIL EVALUATION EXEMPTION rO RM ? �P' /}��.�, herehv cer*:[y thzt the en&ireered plan si ,,ed by me dated—� --{ ;''n ec7ui:� ;ije propeiv, 'ocated at mccts all of the foilowir.; criteria: CENTjc�j�L_�E. • This failed sr•stern is conne,-;c:d to a residential dwelling only. Trier.- are no commercial Or basin:sS uses i-ssoc aced with the dwelling. • The soil IS classified a;,.i•-, •A,C.,C I .nd tl:C PeTC01ution rate, 1,c lejS ih2,.n Or!!qual to S ?inures pe.r inch: The aov'ilCant -nay use h:sto11cal datz to conclude this fa t cr may conduct pre!inain.ary test., a, :1:C s!:C w:i 1:1u; a heaiG: 3�CnC preSen:. Thee is no i.ic.east Ch"dr:gC lIi CSC: p-opused • Thcre arc no variances requested or ner_c;eri. • e b :o Of . e op .s :' .ea ;;i S r';i wil' n e ca di S :n u, ab e e. �Yi a us' ` ; .Un- .v2 r t� e ,ev CIO . ' jLs tt o dw ter bl _Si, c, t ,e ' rrr [("r "er , d % aa^ IC e? / Please complete the fullo�irnd: A) Top of Grcumii Sumac ;if`/ctl(?il (1SIri^ Y_1'i:.) ;ri crma[IOn) a zon 3_21 ad:--�s;merit or � . . 35, J � .D[F I3 ETV-T:.:.N -ind t3 c D,\T is Z — j N B .iec.. uPcn i le ab(,ve Ii•:Gir,dilOn. -Ccwr perm.1t ''us,I be lssucd for __bedrooms rnal:imumi. Nc a(R1:t.enal beC,-ccn'1i are aumc'c-i i- the ;uiU;� isepiic systern puns. - - ----- ---- - — (p ;1:hc.il:h foldcc TOWN OF BWSTABLE L LOCATION SEWAGE # AO02- ? L VILLAGES +Pillre/PVI1L ,P ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)�" ��r�V ;� .2�,[` (size) dL��r /,3• NO.OF BEDROOMS BUILDER OR OWNER _ M01 tr PERMIT DATE: 12 ---,__ COMPLIANCE DATE; Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist, on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ` ro !/ 1 v �1 1y I .' 1 CALL 'DIG SAFE PRIOR TO CONSTRUCTION---UTILITY INFORMATION SHOWN IS APPROXIMATE AND NOT COMPLETE! JOB NO. B01-24 NOTES Money.dwg O%a NOT TO SCAr �o 1. LOCUS IS A.M. 170, PARCEL 35. 00 2. ELEVATIONS SHOWN ARE TOWN GIS SYSTEM DATUMN t0.5'. o� 6 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED AUGUST 19, 1985, w a_ 4. ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED) Q N �50,10 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER. o c 6. COMPONENTS TO BE AASHTO H-10, UNLESS NOTED. w y m 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14", c u n 9,94 8. IF TWO OR MORE LINES, WATER TEST D—BOX FOR EQUAL FLOW �50.4 D—BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET. 9.64 � A 9. DEPTH OF COMPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. o ey 0,28 y/ BUILD UP COVERS TO WITHIN 1' OF GRADE. MORTAR CHIMNEYS IN PLACE. 5 .05 U ONE COVER OF TANK TO BE WITHIN 6" of GRADE. LOCATION MAP / ,33• 4 4 0. 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2" PEA STONE ON TOP. Q PR�25'4 )Z( 51,0 50 78 11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND, CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC. TEST HOLE 1 3 \ 12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR® 15.255(3). DEPTH (inches) ELEV.(feet)/ 51,0 �` 13. PUMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL B LOCK,, AND STONE IN o 51.0 51,00 LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. A layer 10yr 2/2 14. ALL CONSTRUCTION TO MEET TITLE 5 AND LOCAL REGULATIONS, loll sandy loam R1.10.1 - • 51.06 � c? 1.3 51,08 � TEST HOLE DATE: November 28, 2001 B layer sa d 10oarn/6 /4 'fig PERFORMED BY: Ron Cadillac, Soil Evaluator 2� Y 0- 513 \ WITNESSED BY: Perc Exemption Form 2 Cl layer 2.5y 5 6 LOT 13 PERC RATE: <2'-00" inch C2 layer) loamy sand 51, 51,8 y 51,88 52.34t /. ( Y ) �� 15% ravel 51.8 �Kv 51.E 51.43 SOIL SURVEY(1993): Eastchop loamy fine sand 42 ( gravel) 47.5 ` 4 Top Foundation GEOLOGIC MAP(1986): Barnstable plain deposits qdC)L C2 layer 2.5y 5/6 ♦�--- x 51,9 O E med. sand w/trace 85� s.�. Invert 49.67t �. silt—hole holds up Invert 49.15 60 15% ravel( gravel) End. C. I, pipet 3 DRY WELLS " 51,4 ST7�C ��, 51.6 Use Gds Baffle Invert 47.23 75 N y 9 Proposed — 48.83 0� o`t' S.1,6 © `39 O�SS C3 layer 2.5 6 4 5L7 r'' S=3/4 /ft mina cover Top Conc.=47.5 Y Y / 48.80 ^� ti 1'8 NO GRADE CHANGES S=3/4"/ft Top Peastone=47.2 med. coarse sand 51.7 S=Var1eS 48.8 P 4�w 51 ::,:.. 51. ;.:.. ARE PROPOSED In Y. 4 Se40 1500 Gal. s 51,8 n 30 RO Pro opo d (loose) 51.6 no water x 50,6 , � 51,8 "•'•:..:. ::•:.. •.� ""�•:.. x 51,9 T 24 . » 1 3 3 8„ 9.5 ��. 51. . F-V'/5+� 51,6 44.7 / G' k Invert 47.40 Invert 46.70 5 3 17 �R�cF 6 Stone or Compact Proposed Proposed 5.2' Bottom 73 0,8 _ ' 10' NTH 1 � Bottom TH1-39.5 49. T2' s 51J 01 DESIGN DATA m (Adj. high groundwater =36') \ \ N x 50,3 x 5L1 'i52.0 BEDROOMS: 4 \ 50, \1.10 �y,� r GARBAGE GRINDER: No LEACH AREA \ �' •�� REQUIRED CAPACITY: 330 GPD 0USE 3 DRY WELLS WITH 4' OF STONE 7 I x SEPTIC TANK: 1500 GAL. ALL AROUND FOR A 33'-6" LONG BY x 50. A 51,85 0,7 \ \ 51,3 N/F BOTTOM LEACHING AREA: 429.8 SF 12 —1O WIDE BY 2 DEEP LEACH AREA. •\ �i SINCLAIR SIDE3 ' 3 LEACHING AREA: 185.3 SF [2(12.83'+ 33.5') X 2' DEEP)] BENCH MARK--TOP OF WOOD DESIGN CAPACITY: 455 GPD STAKE= 51.85 GIS t0.5' [(429.8 SF + 185.3 SF) X .74 GPD/SF] \ (27'-10" OFF NEAR CORNER GARAGE) \ x 51.4 x 51,6 x 17�SSy�Off, N/F CHAN BENCH MARK--S.E. CORNER OF x 51.2 BOTTOM STEP = 52.26 GIS f0.5' x 1.6 SITE PLAN FOR THIS PLAN IS A VALID COPY ONLY IF IT BEARS N�F AN ORIGINAL RED STAMP AND SIGNATURE. M AXWELL S. & SHIRLEY B . MONEY LEGENDBAHR ��"°FMASS9c ��Q�j"°F�gss\ LOT 13 39 MUSKEGET LAN TH I TEST HOLE LOCATION, NUMBER RONALD ti\ ��� RUNALD y � E, CEN TER VI LLE, M A WATER LINE MARKINGS ° C I A ILFS U DECEMDER 4, 2001 SCALE: 1 "=20' E OVERHEAD ELECTRIC WIRES (IF SHOWN) 3 779 1 G GAS LINE MARKINGS (IF SHOWN) �6•c/s 7 E oA- s\0\ . x 9.5 x &7 EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT) SgNITAR PN suRVE� 6 EXISTING CONTOUR 2 -( © I RONALD J. CADILLAC, PLS, RS g--- PROPOSED CONTOUR PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN j� UTILITY POLE (IF SHOWN) P.O. BOX 258 EXISTING DRAINAGE CATCH BASIN WEST YARMOUTH x — FENCE (IF SHOWN, NOT ALL SHOWN) MA 02673, O TREE (IF SHOWN, NOT ALL SHOWN) HEALTH AGENT APPROVAL DATE (508) 775-9700 C 2001 BY R.J. CADILLAC PAGE 1 OF 1