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Home My WebLink About0122 AMELIA WAY - Health 122 Amelia Way Marstons Mills P A = 148 003002 Commonwealth of Massachusetts 1418-005-ov Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 122 Amelia Way Property Address Benjamin Owner Owner's Name information is MA 02648 12/28/20 required for every Marstons Mills, 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. A. Inspector Information Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12/28/20 Inspec o Signatur 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 122 Amelia Way Property Address Benjamin Owner information is Owners Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 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 !/e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .v 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 ❑ ® 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 t5insp.doc-rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name req u i red for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•� 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Citylrown 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 ® ❑ 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? ® El available 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts re Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner Owner's Name information is required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom permit on file Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �. o� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): 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: Pumped October 2019 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26P20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. City/Town . State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Original septic tank, new d-box and leach chambers 2008 per BOH record 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): 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 II c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner Owner's(dame information is required for every Marstons Mills MA 02648 12/28/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 g feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet cover raised to 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 1/2 �2 Distance from top of scum to top of outlet tee or baffle �2 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �e ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 D-box is 3' below grade, cover raised to 6" of grade, no adverse conditions observed l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,a ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •V, 122 Amelia Way Property Address Benjamin Owner Owner's Name information is required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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 Official Inspection Form t e 5 �~ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 P Y rY �e 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown 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.): Chambers were video inspected, effluent level is approximately 1' below the invert at this time, no indication of past hydraulic failure 12. 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 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 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityfrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I 12/30/2020 Assessing As-Built Cards TOWN OF BARNSTXBLE CATION LO !�ot t mel L Wa L4 SEWAGE 8 VILLAGE r Oa cs M,- 1 Yl,(L_ASSESSOR'S MAP 8t LOT t4 INSTALLEWS NAME&PHONE NO. � + g Ot t tr Co I �4� OS3O SEPTIC TANK CAPACITY lmn ion LEACHING FACILITY:(typef �n (size) �5� X t—10 NO.OFBEDROOMS 3 BUILDER OR OWNER W t nC ae:6n PERMITDATE: t_.`)I I OP, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ,r Qkxn 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)p_L +g O�(e Z� Feet Furnished by Gu L7lln. 4-�B� sr` Deck 4"s4,1 +eG 1 '1T ' } \Tb , 3 ' �c l 1930 JW ► "A A1' v S A-600 O(Ion d.yuel� X(- 4- https://www.townofbarnstable.us/Departments/Assessing/Property Values/HMdisplay.asp?mappar=148003002&seq=1 1/2 Commonwealth of Massachusetts ,if Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •/ 122 Amelia Way u- Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >12'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: 2008 NGW 144" Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health -explain: 4' seperation per 2008 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 54'msl and nearby surface water at 34'msl You must describe how you established the high ground water elevation: See above i 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 ,qi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Property Address Benjamin Owner information is Owner's Name required for every Marstons Mills MA 02648 12/28/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Z. TOWN OF BARNSTABLE LOCATION J aQ Am SEWAGE # r5 VWLAGE roa rSLns M,I Is ASSESSOR'S MAP & LOT 14 INSTALLER'S NAME&PHONE NO. _f )o)n + F>Ou.r Co TnC �43dL�oSvo SEPTIC TANK CAPACITY _ 1. C� GCJ Ion? (s.ie z )•.�LEACHING FACILITY: (type C A6w ]O NO. OF BEDROOMS ' BUILDER OR OWNER Th O hr O- W YY)r- aJ-')O r) PERMITDATE: t Q i 60 COMPLIANCE DATE: — 4i�za Separation Distance Between the: C, 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 Q�LJL'(�,��,/ �� FS,r fY 00, op l k J Deck 4 tlourdte��, 30 jil o L G✓c-f 5he0 61 urpur,d 51 TOWN OF BARNSTABLE LOC.ATiON 10)o� I Q WQg4 SEWAGE # VILIAGE �� ASSESSOR'S MAP INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY O� LEACHING FACILITY:.(type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 V�5� 1L� A � ouFa 6 m q4q Ac 4 � C Ab � 4 No. .2,06b ��3 l Fee /00 c^ R THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for Oigozal *p5tem Construction 3permit Application for a Permit to Construct( ) Repair X) Upgrade(Vfe4bandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. eA wL OfOer� Naam Address,and Tel.No. Assessor's Map/Parcel 148 ( �� tta,i K.t 1 Installer's Name,AdA s,an vel No. F3 t�l4 �-T� Designer'sNaalme,Address and rTel�No. sO C(GJ IILU,� g ,•� W 1 A N� (�.at cacti J Y11 U264S p �i -' �- Type of Building: _ O Dwelling No.of Bedrooms Lot Size Ji UU� sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 1J� gpd Plan Date —L ?j ( Number of sheets Revision Date Title Size of Septic Tank Py..1-�A— t000 Type of S.A.S. Description of Soil LtA-rn Nature of Repairs or Alterations(Answer when applicable) R ctt, 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 Health. Signed Date Application Approved by Date 1 2 ' 40, 6� Application Disapproved by• Date for the following reasons 7 Permit No. 2 DD s S�3 Date Issued Z A& 01 ------------ _.::: �,.. — •--•+•r ^1 r«v �y - ....._...,�.-s.,..cv-�-.--,...•-�.,,r....�,,.,,..,,..:... .- -r�...w.w.—....._—._r,,a►.:.,..,.s,,.. _+rs•'+•....o-Y'�t�'"''nq� r.,.;r..o•�- ..••Y+•-•'r-•S""- r ."�'✓; No. G U� — � 1_ F �'. / � l/. : Fee �00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION r TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZfpPYtcatton for Migplar bpgtem Con5tructton 30ermtt Application for a Permit to Construct(.) Repair) .Upgrade(VI Abandon(") ❑Complete System ❑Individual Components Location Address or Lot No. Amej tQ 0 'ner's Name,Address,and Tel.No. G t 40c) c��1 ' 1 0Ma IU_ Y1`1'1G1�(10.F16(1 Assessor's Map/Parcel ' 148 r10l/� 1 t(L p � Q '', rt (Cl V5 Installer's Name,Address,and Tel.No. i�Li►� U loll y �� Designer's Name,Address and Tel.No. s 4 Gam-cec W�Sk. ,{'—c �e he,n J' (-b le k o2tC � 'lope of Building: O 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 I Z �j og Number of sheets ` Revision Date ` Title Size of Septic Tank e-4y4y� tL)OD Type of S.A.S. �� -c�r� ut_(�5 Description of Soil Nature of Repairs or Alterations(Answer whe applicable) Rk _-p,F, Pt-4- 1 M� -EIn S 6—v I r,,�_c.i Lm C{r s-f wt` sr Date last inspected: Agreement: The undersigned agrees to ensure'the construction and maintenance of the afore described on-site sewage disposal system in rg P Y accordance with the provisions of'Title 5 of the Environmental Code and novio place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed ( Date `� t( o� Application Approved by Date 1 Z Application Disapproved by Date for the following reasons Permit No. Z DO .513 Date Issued ——————————————————— ——---- - ------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (t' ) Upgraded ( ✓}� Abandoned( )by l 6,1?j A, / (,, { n G at 1 Z 2, IA M f U 4, yyA pr1A(LSfv►�� •t t,S has been constructed in accordance with the provisions of Title 5 and the 0 Disposal System Construction Permit No. Zoos-15-13 dated 1 Z 1(, Zo Installer Z 6 V Designer 00 L #bedrooms S Approved design-flow �(� jl0 gpd r The issuance of this�p}ermt shall not b�ejcos/trued as a guarantee that the system will funjdonfasdesigne / d} Date /J /,•�L/l1/fl/�-A Inspector aCl/lif --------------------------------.y-------- No. �O d�j-�� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1wtgpoal *pgtem Con5tructton J)ermtt Permission is hereby granted to Construct ( ) Repair (/1 Upgrade ( ) Abandon ( ) System located at 1 2 2, /> rA iL L IA Vv/-\-1 C,T v+,j C. 'r,'t k L and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pe it. Date 1 Z �►(�l 0 v Approved by JHI1.Gb.0607 1 m jir n VHKIY51 HULL GUHKL Ur MLHL 1 H 11U.011i r.C/C i Town of Barnstable . c regulatory Services Thomas F. Goiler, Director l L Public Health Division Thomas McKean,Director 200 Main,Weet, Hyannis,MAC 02601 office: 508-862-4644 Fax: 508-790-6304 Date: JQ Sewage Permit# s-5(3 _ Assessor's Map/Parcel 148 Installer&Designer Certification Form -e hem J -Dod c, ,r A-Y7SOc(a." Designer: Installer: P_,A>,ef+ g X Co T-nc Address: q,- u _Ca� Address: r SST FyJcro .� lA b�s3 tV. cu w C� ►M `c)a G4 s On gJaCA E C)"J, Lo 1 c was issued a permit to install a (date) (installer) septic system at Ia.:)- e-A t a �lilla�c-� _based o a design drawn by (address) rfVrs+ons x 50 c dated 1'�_ -0 3 08 (designer) I ceift that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the disttibution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e, greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. tR f�� OF Mgssq 5 f • l P " Q� p R©BERTA. cyG (Installer's Signature) 1 f(Cf_ � " CIVILE r `f o v 9 No.41642 O T A)- A °qp`cQISTEP�� (Designer's Signature) (Affix Des' a .t p`Here) PLEASE RETURN TO BARNSTABLU TUBIC HEALTH DIVISION. CERITFFICATE OF COMPLMCE WILL NOT BE ISSUED UNTIL. BOTH THIS FORM AND_AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC REALTH DIVISION. THANK YOU. q:\offlce flo mAdeegnemer0cadon form.doc Town of Barnstable P# aF�� Department of Regulatory Services wuasresre Public Health Division Date �A i639 16� 200 Main Street,Hyannis MA 02601 e Date Scheduled WTime 0 � Fee Pd._ Soil Suitability Assessment for Sewa a is offal 1 0 yt'�P PerformedBy:_ �i��171�f�).1� � r�� 1.,,I% Witnessed By; P ��11J )J� LOCATION& GENERAL INFORMATION , / Location Address i L ` 4 �� Owner's Name MAKSTaN5 rnl(CS Address IZ: Assessor's Map/Parcel: l y g(0t.,2'cc Z Engineer's Name �W Kle_, P.C. NEW CONSTRUCTION REPAIR Telephone# y / -C.7 3 Land Use Sl °� opes(�o) Z Surface Stones Distances from: Open Water Body L 1 y% ft Possible Wet Area_>l J_ft Drinking Water Well -&-4- _ft Drainage Way <= 8 Y S�' ft Property Line 2 LO _ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands(n proximity to holes) LLj 00 �.I cr) f 40 C—D 1 v CID 73,1Z Parent material(geologic) Depth to Bedrock Depth to Groundwater. Stan�ingWaterin Weeping from Pit Face Estimated Seasonal High Groundwater t-L G• it \ DETERMINATION FOR SEASONAL HIG '6uATER TABLE Method Used: "U VJn. z 1��:.ltt>ye:��%1cdLtY►tr�t� ir/t.td'L.�,.S Depth Observed standing in obs.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole: in, ©roundwater Adjustment ft, Index Well# Reading Date: Index Well level.,, AdJ,factor— Adj,Groundwater Level ,y PERCOLATION TEST bate +y e . Time F rvation# �_ Time at 9" - Depth of Perc Ca t�� Time at 6" Start Pre-soak Time @ I :v 'Time(9"-6") End Pre-soak Z Ak Z, 4,vvo pJ6 U t,.b il't��,►y.. �.� Rate Min./Inch �- ?. /' �yr� ��✓ Site Suitability Assessment: Site Passed�! — Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at.least one (1) week prior to beginning. Q:\SEPTICVERCFORM.DOC sk? DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil er Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. on i ten ravel A r3�c, 0 i o S L-. \0`t lz. 4 ' Ceti Y.k.i.Si A-m 5. L;rurL;S DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% e . 0 2 h✓l v'�. c;�u ,— ��.,.,,�,-tip, �zu H�.•- V Aa. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Grave DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. I Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us material exist in all areas observed throughout the area proposed for the soil absorption system? 7-_J ,.w If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expe' e, and experience described in 310 CMR 15.017. Signature � \: Date ! i7 Q:4S.BMCVERCFORM.DOC r , Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Martsons Mills MA Property Ad Vane M and Thomas W McMahon 122 Amelia Way ° Owner Owner's Na Information is M arstonS Mills MA 02648 8/30/2011 required for every 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: A. General Information When filling out forms the Joe Martins computer,use 1. Inspector: Accu Sepeheek only the tab key 17 Northside Dr.-'- to move your S. Dennis, MA 02660 cursor-do not use the return Name of Inspector key. . —I Company Name 8 >aab Company Address C:) 3 i rs City/Town 50 8� ' ��/ State Zip Code 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (31 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local revMg Authority In pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner, and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I t5ins•09108 Title 5 Official Inspection Form:Subsurface`` p ge Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Martsons Mills MA Property Addr�gJane M and Thomas W McMahon 122 Amelia Way Owner Owner's Nam.1 M Information is arston Mills MA 02648 8/30/2011 required for every page. City/town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 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" onditional Pass"section need to be replaced or repaired.The system, upon completi of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not dete ed" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and o 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhib' substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if t existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal se ' tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Complian indicating that the tank is less than 20 years old is available. ❑ N ❑ ND (Explain below): t5ins•09108 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 122 Amelia Way Martsons Mills MA Property Ad"Mane M and Thomas W McMahon 122 Amelia Way Owner Owner's Na Information is ?Aarstons Mills MA 02648 8/30/2011 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ 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 BZHealth' ❑ broken pipe(s) are replacedN ❑ ND (Explain below): ❑ obstruction is removedN ❑ ND (Explain below): ❑ distribution box is leveled orN ❑ ND (Explain below): ❑ The s em required pumping more than 4 times a year due to broken or obstructed pipe(s). The Sys m 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 Re red by the Board of Health: ❑ Conditions exist whic quire further evaluation by the Board of Health in order to determine if the system is failin o protect public health, safety or the environment. 1. System wi ass unless Board of Health determines in accordance with 310 CMR 15.303(1)( at the system is not functioning in a manner which will protect public health, safety a the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 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 122 Amelia Way Martsons Mills MA Property AddMhne M and Thomas W McMahon 122 Amelia Way Owner Owners NarlatSt011S Mills MA 02648 8/30/2011 information is required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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 lic health, safety and environment: ❑ The system has a septic tank and soil absorption system ) and the SAS is within 100 feet of a surface water supply or tributary to a surface wat upply. ❑ The system has a septic tank and SAS and the S is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS an a SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS an a 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 w water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent a the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provide 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 ❑ E/ 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 ❑ d Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6° below invert or available volume is less than '/2 day flow t5ins•09/08 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 122 Amelia Way Martsons Mills MA Property Ad M and Thomas W McMahon 122 Amelia Way Owner Owner's Naazstons Mills MA 02648 8/30/2011 Information Is lV1 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 02 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Ej/ 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. ❑ I td' 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.) ❑ RI/ The system is a cesspool serving a facility with a design flow of 2000gpd- / g The s ❑ lr�1.,'/ 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 e a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"t ch of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wit . 400 feet of a surface drinking water supply ❑ ❑ the syste s within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the stem is located in a nitrogen sensitive area (Interim Wellhead Protection ea—IWPA) or a mapped Zone II of a public water supply well If you have ans red "yes"to any question in Section E the system is considered a significant threat, or answere es" in Section D above the large system has failed.The owner or operator of any large system sidered a significant threat under Section E or failed under Section D shall upgrade the syste in accordance with 310 CMR 15.304. The system owner should contact the appropriate regi al office of the Department. t5ins•09/08 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 r` 122 Amelia Way Martsons Mills MA Propeq Add ne M and Thomas W McMahon 122 Amelia Way Owner Owners Na Information Is Warstons Mills MA 02648 8/30/2011 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No 2/ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ U31 Were any of the system components pumped out in the previous two weeks? E ❑ 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) ,,_,/ El Was the facility or dwelling inspected for signs of sewage back up? Ltd ❑ Was the site inspected for signs of br k out? G ❑ Were all system components, ding the SAS, located on site? Lid ❑ 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? 10 ❑ 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: IE ❑ Existing information. For example, a plan at the Board of Health. m/ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue 4x approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms actual DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09/08 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 122 Amelia Way Martsons Mills MA Property Add Mane M and Thomas W McMahon 122 Amelia Way Owner Owner's Narrtal•StOnS Mills MA 02648 8/30/2011 Information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: lbo - ._o 1tiPils AJ Number of current residents: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: r 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. Grease trap present? ❑ Yes ❑ No Industrial olding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Martsons Mills MA Property Add Mane M and Thomas W McMahon 122 Amelia Way Owner Owner's NamjVjg,arstons Mills MA 02648 8/30/2011 Information Is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: //0� M /QQ/l �vVi10i� Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil 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•09/08 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 122 Amelia Way Martsons Mills MA Property AdViane M and Thomas W McMahon 122 Amelia Way Owner owners Nar>ie� Information is lVlarstons Mills MA 02648 8/30/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) A prod tee of II components, date installed (if known) and source of information: i►�s-��1Pd �v� �- Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 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: feet Material of construction: k-oncrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certifIca e) El Yes El No Dimensions: XV7 Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Martsons Mills MA Property AdViane M and Thomas W McMahon 122 Amelia Way Owner Owners Na Information is 14arstons Mills MA 02648 8/30/2011 required for �Y every page. C frown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) a 11 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness fl Distance from top of scum to top of outlet tee or baffle 1 �f" Distance from bottom of scum to bottom of outlet tee or baffle - How were dimensions determined? co k-e�kek Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): A Mffi0Xd() as so s')� ld v 104 c, T n I f V -I- /1 t- 14H -oAetave L6N t 0 kue I q8 Grease Trap pocate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiber ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from to scum to top of outlet tee or baffle Distance fr bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 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 Wj 122 Amelia Way Martsons Mills MA Property Addtne M and Thomas W McMahon 122 Amelia Way Owner Owner's NaTA Information Is TA Mills MA 02648 8/30/2011 required for every 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 pu ed 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 Alarm present: ❑ es ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alXafloat�switches, etc.): `Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /" Property Address M and AeMgs wA/yQkOA Amell -t Wrt Owner Owner's Name Information is fT- f A �S A#- Q2 4 Y8 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): S ge Levtj q 2u 61-C, un yj e ite A) Yin v ale r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump mber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site , excavation not required): If SAS not located, explain why: t5ins•09108 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 r` 122 Amelia Way Martsons Mills MA Property Add Mane M and Thomas W McMahon 122 Amelia Way Owner Owner's Nam1Vl@�arstons Mills MA 02648 8/30/2011 Information Is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number i 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.): ©vAz. e ov�.�vLo-&C td.=u n�v p0 N 0, A) CL 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 constru ' Indication of groundwater inflow ❑ Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Amelia Way Martsons Mills MA Property Addrggsane M and Thomas W McMahon 122 Amelia Way Owner Owner's Nam information Is e `arstons Mills MA 02648 8/30/2011 required for every page. Cityrrown 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 sitZplan)�: Materials of constr Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, leve�hding, ondition of vegetation, etc.): t5ins•09/08 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 122 Amelia Way Martsons Mills MA Property Address Diane M and Thom as W McMahon 122 Amelia Way Owner Owner's Name Information is Marston Mills MA 02648 8/30/2011 required for every page. City/Town Satet 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 ublic water supply enters the building. Check one of the boxes.below: hand-sketch in the area below ❑ drawing attached separately f D 5- � � g 3 _Z1. D F STTT ICES ' oJ _ 0j , ^^ B3LIS t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r` Property Add r 122 Amelia Way Martsons Mills MA Owner Owner's Na m$ `.MarstonS Mills MA ane M and Thomas W McMahon 122 Amelia Way information is 0264&_ 8/3012011 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: heck Slope [Surface water [Check cellar MShallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: 92 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: I& M470 -fl24MPIM )a I k"C, You must describe how you established the high ground water elevation: ZPas�✓l,Q� 3 . 6 �' tAs�ile- 612d✓AJw44r Qp — C^16vk- At 1� - �V/Ie sD w c�C �4 Qs-e �o, � 6liqq z = 3 f 3s-•1-3 - 8 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins,09/08 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 122 Amelia Way Martsons Mills MA Property Address Diane M and Thomas W McMahon 122 Amelia Way Owner Owner's Name Information is Marston Mills MA 02648 8/30/2011 required for every page. Cityfrown 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF NIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION m F 2 p, n r w I � tl h � W TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION \l Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 ��'6 vY�bb� U`�"?S Owner's Name: JOAN LI,SEE Owner's Address: 122 AMELIA WAY MARSTONS MILLS,MA 02648 Date of Inspection: 3/20/02 Z 3 (0 b Name of inspector: (please print) JOHN GRACI RECEIVED Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 MAR 2 8 2002 Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE HEALTH DEPT. CERTIFICATION STATEMENT 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: X Passes _ Conditionally a ses _ Needs Furthe aluation by the Local Approving Authority Fails Inspector's Signature: '- Datc: 3/20/02 The system inspector shall submit a opy 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. Notes and Comments SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes'conditions at the time of inspection and under the conditions of use al that tiwc.'I'his inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 122 AMELIA WAY MARSTONS MILLS,MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as,approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a 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 Certif►cate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ .broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 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 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 n/a **This system passes if the well water analysis, performed at a DEP certified laboratory, for coli form bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a 'Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 D. System Failure Criteria applicable to all systems: You miml indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded.or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water e'.evation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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. IThis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.I (Yes/No)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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone If 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 owl er or operator of any lame system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. 'I'hc system owner should contact the appropriate regional office of the Department. a 'Page 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period " X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site X _ 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 '? X _ 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: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN''SPECTION FORM PART C SYSTEM INFORMATION Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection. required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): W*ZDOO` i 3(Q,00C) Sump pump(yes or no): NO Z00i- 1 Q?-id0!) Last date of occupancy: n/a COM MERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 4 YEARS BY OWNF,II Were sewage odors detected when arriving at the site(yes or no): NO � r 'Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance fi-om private water supply'well or suction line: n/a Comments(on condition of joints, venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance fi-om top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, sh uctural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 I Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X.(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a 0 leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. PIT NEVER HAD MORE THAN 2' OF LIQUID IN IT. BOTTOM IS AT 10'. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 'Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM VSPECTION FORM PART C SYSTEM INFORMATION(contini,ed) Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN L1SEE Date of Inspection: 3/20/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r GIVI ABM Dec k- o A u � 4A � C AB qq k O° D 0) 113 & �L 5� in Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 122 AMELIA WAY MARSTONS MILLS, MA 02648 Owner: JOAN LISEE Date of Inspection: 3/20/02. SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(a�outting property/observation hole within 150 feet of SAS) NO Checked with loyal Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. h 5 IZZ TOWN OF BARNSTABLE �— �• LOCATION In 8nl9��A W� SEWAGE# � y VILLAGE IogSIcn s• IV-N t S ASSESSOR'S MAP & LOT/46 c.1�s-�e2 INSTALLER'S NAME&PHONE NO.rZeC-O ..SEPTIC TANK CAPACITY c' `;LEACHING FACII.TTY: (type) [Q�ac h.�� 21 S (size) 1060 AA L 9 '•>'.NO:OF BEDROOMS 3 _ :Bt-MDER OR OWNER �1 S+cic v:1 25 PERMTTDATE: 3•_ _ S COMPLIANCE DATE: Separation Distance Between the: +' '.'Maximum Adjusted Groundwater Table and 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 6 Z � s' 1 yb 's, S(r I•Z Z TOWN OF BARNSTABLE • LG eATION Lf-C 0 nt Ui, is-'P SEWAGE # IS' NrLLAGE 5'7c»5. EVIL ASSESSOR'S MAP & LOT fglcb INSTALLER'S NAME&PHONE NO. zCv SEPTIC TANK CAPACITY � LEACHING FACILITY: (type) taX (size) 1 c!00 SA NO.OF BEDROOMS 3 BUILDER OR OWNER �'el� va,c �S PERMTTDA'TE'l COMPLIANCE DATE: 11 .11 'J Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 I Furnished by . j 4 C �Z G 4 P- qF Pd� No........................d A Fa$.......`DD.. THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH TOWN OF BARNSTABLE Alip iratioit for DioVo!3tt1 Works onitrttrtion Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal 6stern t: ............ ............Z- --------- ��----------4�/27�9 a tio dr ,r cN.o r. L. caam ----- Owner �Ad-------- s -G--Snstaller Address d Type of Building Size Lot_S�_ ,I�.Sq. feet V Dwelling—No. of Bedrooms____.._...__________________________Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building W_ > -No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures --------------------------------- - ---_----- w Design Flow......�._`�_�...............................gallons per person per day. Total daily flow..____... .__L?___..._............g al�ons. WSeptic Tank—Liquid capacitylrw__gallons Length-_/.0....... Width...s..-..._ Diameter---------------- Depth,'--,../.....__.. x Disposal Trench—No. .................... Width______1_�._.._._.. Total Length.____._ �__..._--_ Total leaching area---------._.__...... q. ft. Seepage Pit No....... .......... Diameter._ ----- Depth below inlet.;W........... Total leaching ar � Z Other Distribution box ( ) Dosing tank ( ) � aPercolation Test"Results Performed by.._GJ. ------- '. -r...... Date--_-_��.__�-2__1..7__...... ,a Test Pit No. 1.- .. inutes per inch Depth of Test PiV_,4.ly-_-_.__. Depth to ground water-e(.f.d �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-__---_----_------.-. --•-•-----------------------------------------••-----•----------•--•••---•--------...._. Description of Soil s _.gip-C �✓...----- x w UNature of Repairs or Alterations-Answer when applicable.............. ................................................................................. --------•-----------------•---------------------------------------•-- --.._..-----------••-----•--••-------------•---•-------•------------•------------------•------._...-----------------------------_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com as be n issued by t board of health. Signed ... ......�.. .. ... ... . .. .. l e :.----- Application Approved By .... ... '. ....f...c...... ...... ---------- Date Application Disapproved for the following reasons: ................................................................................ . . .............................. ..............................----.-...-..----------------- --------...-............----------.............-----..............----------------...-----------------..------------------------------- -------------------------------------- QQ Dare Permit No. -----------1.5.- ...1�l510--- .. Issued ............. �..7....`�. . - .. Dare p U y t .,E. �t P �o ova 40 i•''�`-,",` �, THE COMMONWEALTH OF MASSACHUSETTS_. _M BOARD OF HEALTH , +� TOWN OF BARNSTABLE d� Appliratioit for Diin.pwial Worbi omitrnrtion ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal stem t G � __..._._...t� �l_ ..........lL: '��G 'V ="LL.S-• ----C�U/ c Ce Location,' -Xnd re§s or Lot No. owner Ad ess Installer Address Type of Building Size Lot--- _.�y_ __t�_Sq. feet Dwelling— No. of Bedrooms--- Expansion Attic ( ) Garbage Grinder ( ) a_ Other—Type of Building �U?1T,/� No. of persons____________________________ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------- ---- - - W Design Flow......Z;�___________________________gallons per person per day. Total daily�flow----------I _ ...................gallons. WSeptic Tank—Liquid capacity/S'A.galIons Length-_Zo_..___ Width---- Diameter---------------- Depth ......... x Disposal Trench—No_ ____________________ Width.___...__......... Total Length-------- �______-_ Total leaching area....................sq. ft. Seepage Pit No........ ..___-._ Diameter-__-0a.__.... Depth below inlet___________ Total leaching area,��,.9,ysq—€i z Other Distribution box ( ) , Dosing tank ( ) q4�z> '-' Percolation Test Results Performed by.... 4c.4" __ ,�'�_ '.�___._ Date......_ Test Pit No. i__- _?minutes per inch Depth of Test Pit;/ 5.,/ _`'___ Depth to ground 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 04 1 ..---•••--••----------------------------••------------•--•-•---•-••--•--•----................................................................................ D Description of Soil-------... - ---------------------------------------------------------------- W U ............... ••••---• •••••••-••---•••-•-•---•••••----------•-•---•--•----•-••-•--•-•••---••---------•-•----••--••••••-••----••-•--•--•------•--•-----•-----•••-•-------•--------•--•••------•-••-••- W ---------------------------------------------------- --------------------------------------------------------------------------- ----------------------------------------------------------------••••-- UNature of Repairs or Alterations--Answer when applicable--_.__...._-__________________..____.-.-__-_-_-__--____----_.--_-__-_-__-__________________- -•-•---•--•------------------•••--...------•-•--•---•••--•----••••-••-----••-••-•---•-...•--•-•--------•-._..._......---------------------•-•--•••••••-••------............--••-----•-- ........--•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl*Rea as been issued by the board of health. / �-z / 7 Signed �' �e4lDa Application.Approved By ----L " - .......t.C.`... ........... ......' - /-- -------------------_----....... Dare Application Disapproved for the following reasons- --- ----------------- ----------------------- ------------------------------------------------------------------------------------ ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- Dare Permit No. ---------- .-�... �� Issued ..............?.-�---7......9................. Date ----------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ( `I TOWN OF BARNSTABLE 1011erttftrate of Complianre Th 6-is 0 =- -. That the Individual'Sewag Disposal System constructed ( �) or Repaired ( ) by .---------._................ .._................ at ........ -�......F........... ------��I_.... L ---------- has been installed in accordance with the provisions of TITLE ��The Stave Environmental Code as describe in the application for Disposal Works Construction Permit No. ......... dated .....3..-1.2.... p._._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r ' DATE // (Z -q -- Inspector �... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE boo No....................... FEE........._..---......... �i nstt1 r on tr hermit Permission is hereby granted_.._ . ,"'' to ConstCr�uyctt or/�D`epair ( ) an Individual SSeq[!,/w�age Disp//o/s/ah System at No.. ?1..}- (=--l�Vil K l.(/cc,`✓.Y ��l? ----.•------------------------------•------•-----..............__..------....-- St r`et a as shown on the application for Disposal Works Construction—P�e�r i No.-.S-----_L; Dated_-__ 3---.--_---_------.�`S............. ✓ Board of Health DATE-----//...-....�------ --•---•----------•------------------•• � FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS TEST HOLE LOG DATE-. j-L5-7- a81--- TEST BY:WELLER&ASSOC. WITNESS :. PERC RATE:.-=-� �iy/, - Y /7S z -- ,�6D/3J_iy: g sy I S �j DESIGN DATA I DAILY FLOWEO)2 x; - • SEPTIC TANK:f—o.. -_aT50."/0= LEA G FACILITYi 73> f 2S ti �'_ S USE: A ° CAPACITY: SIDEWALL��. S s.�$ e-'_ BOTTOM:==7j ��--�8-��--.. �j TOTAL7 cSP.m 77 7) f'i if4Gc_°. r tea' '}:`'i..'r`�� ;j'�S.y�yzn,�` � ,s: i,�� .. .. ..r �f ' - '�:'. :.z,.e :.�..��5 3:J�'-.-c��.��.'.."�� C.:�.•.�'.c, ... PIPE TO BE LAID 2"LAYER OF 3/9"PEASTONE LEVEL FOR ;' OUT OF OVER 3/4"-1 1/2" WASHED DISTRIBUTION BOX STONE ALL AROUND TOP OF FOUND. ®EL. 7 .0� 10" 14" ° 10� zs s 8 ae yz,sa ALL PIPE TO BE 4"DIA.SCH 40 PVC -Z RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6" OF FINISH GRADE THLS SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL SEWAGE SYSTEM PROFILE SCALE: 1"=10' DANI!L F. HAMANA,3 Ji aaRr7.. � CIVIL GE."AAL, 01'ES_ No.32686CO y I. ^� CONTRACTOR TO BE`R85pONSIBLE'FOR THB SITE-SEWAGE PLAN w� �rsTE� ,w LOCATION OF ALL UTILITIES,ABOVE AND'�� k"- , FOR fs''IQXAL E � UNDER GROUND,PRIOR TO ANY CONSTRUCT �t. OR EXCAVATION. A,.. w S 2. INSTALLATION OF SEPTIC SYSTEM TO.BEIl�T qA ° PREPARED FOR COMPLIANCE WITH 310 CMR'15.00:TJTL V,F t ; 0 Of Mq�J 3. THIS PLAN IS NOT TO BE.USED FOR PROPERTy� - , LINE DETERMINATION.'. - tJ$ine-� //gq5��LE5 STpEIIpE�N�yW. f ,i..t SAP/•.J!�� T �. R�IVISA4f`�`• NO.35791' '=a 3 ASSOCIATES �E WEI.LER & � J P.O.BOX 119 YARMOU E PORT,Am 02675 (508)362-8131Mr h APPROVED BY: TEST HOLE LOG TEST BY:WELLER&ASSOC. WITNESSA_._::::8:9 .e. 1 PERC 1 Jos\ O" So,o • s yz y�,s N - - r9T�/Z C cc ti DESIGN DATA DAILY FLOwEo -p I Q ` SEPTIC TANKE::33o. .. - , ' LEAC G FACILITY: _ USE:.(/ G'�_Cv G:P f 73, As Z Sa CAPACITY:Y�� BOTTOM• TOTAL-- :7_%.0140,40 Ga7- 7� 1 y� 0414tA+�'+r ,Y•t"C�.} ' PIPE TO BE LAID 2"LAYER OF 318"PEASTONE LEVEL FOR 2' OUT OF OVER 3/4"-1 1/2" WASHED DISTRIBUTION BOX STONE ALL AROUND TOP OF FOUND. r10" 14" moo,�� y�S� y88e � 6� '•-�. z5 y8,ss yz,s8 ALL PIPE TO BE 4"DIA.SCH 40 PVC Z? (p• Z� • RAISE ALL APPLICABLE MANHOLE !b' COVERS TO WITHIN 6" OF FINISH GRADE THIS SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL SEWAGE SYSTEM PROFILE SCALE: 1"-101 DANI!t E. IRAMAN r' i 11 +aPk 2' V NoCIVIL GENERAL N ,_ < i 1. CONTRACTOR TO BE R=MNSIBLE'FDR THE:' SITE SEWAGE PLAN LOCATION OF ALL UTILITIES,ABOVE ANDS OJ1AL E UNDER GROUND,PRIOR TO ANY CONSTRUCT'i FOR OR EXCAVATION. Z. INSTALLATION OF SEPTIC SYSTEM TO.BEIl�T,r COMPLIANCE WITH310 CbIR iS.00:TITLEV,� r h '� PREPARED FOR rot { r N Of Mqf 3. THIS PLAN IS NOT TO BE USED FORPROPER'1'Y �eel LINE DETERMIINATION..UIEVO SCALE:,.*. M-DATE:.—ter: _` . 35191 , ikin.i r3" & ASSOCIATES 3.9•gS .. r ^�, , ; y , .P.O BOX 119 YARMOUTHPORT MA.02675. (98)3624131 APPROVED BY: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INLET + OUTLET ACCESS COVER TO BE LEACHING FIELD BROUGHT WITHIN 6" OF FINISHED GRADE GENERAL NOTES 1.) THE PROPOSED LEACHING FIELD SHALL CONSIST OF 2 - 500 9"MIN., 36"MAX. FINISHED GRADE OVER GALLON LEACHING TANKS WITH 4 FT. OF 3/4" - 1/2" DOUBLE WASHED 9'-6" DISTRIBUTION BOX = 52.25' :f: STONE AS SHOWN ON THE DETAIL SECTIONS ON THIS PLAN.DIST 0 1.) UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND 9. 24" DIA. MANHOLE REMOVABLE COVER 5- DIA. OUTLET(S) CONSTRUCTION METHODS SHALL BE IN ACCORDANCE ------ 6 MAX. 2.) THE GROUND ELEVTION AT THE LEACHING FIELD IS AT EL. 52.25' WITH TITLE 5 OF THE STATE ENVIRONMENTAL CODE AND ANY 3- 19" COVERS THE ELEV. AT THE TOP OF THE LEACHING FIELD IS AT EL. = 49.66' APPLICABLE LOCAL RULES. PROVIDE WATERTIGHT THE ELEV. OF THE 4" PVC SERVICE PIPES ARE AT EL. = 48.83' M It C4 00 I I i i I -, !j JOINTS(TYP.) r '4PVC IN FROM THE ELEV. AT THE BOTTOM OF THE LEACHING FIELD IS AT EL.= 46.53' 4' LIQUID LEVEL (__SEPTIC TANK 2.) ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD k, 1 4 PVC OUT FROM LEACHING FACILITY. OF HEALTH AND THE DESIGN ENGINEER. TEE �5%-O" OUTLET ILITY. MINIMUM SLOPE I X ---------- ------------- 49.13'± 49.30' 6" CRUSHED STONE 3.) 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL __JOUTLET OVER MECHANICALLY BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. COMPACTED BASE LEVEL BASE 3 OUTLET DISTRIBUTION BOX (H-10) PLAN VIEW ......------------ 4.) 4- SCHEDULE 40 PVC PERFORATED PVC PIPE SHALL BE USED \-6" CRUSHED STONE TO BE RESET ON A LEVEL STABLE CROSS SECTION VIEW :R MECHANICALLY BASE. FIRST TWO FEET OF OUTLET PIPES INSIDE LEACHING TRENCHES OR LEACHING FIELDS. COMPACTED BASE TO BE LAID LEVEL. 12'_10" 5.) SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. CROSS SECTION VIEW EXISTING 1,000 GALLON CONCRETE SEPTIC TANK(H-10) LENGTH 10.50' WIDTH 5.67' DEPTH 5.33' DISTRIBUTION BOX DETAIL ------- 1 6.) THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. EL.4 48.813'_/ 2= EL.= 48.83' Cus N.T.S. SEPTIC TANK PROFILE 7.) LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED > > N.T.S. 0- a. PRIOR TO BACKFILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS NOT TO BE BACKIFILLED WITHOUT FIRST OBTAINING APPROVAL FROM THE BOARD OF HEALTH PLAN VIEW AND DESIGN ENGINEER. TOP OF FOUNDATION FINISHED GRADE OVER 20" MIN. ACCESS COVER (EL=53.00') DISTRIBUTION BOX 52.25' (TYPICAL OF 3) FINISHED GRADE OVER 9. 8.) ELEVATIONS FINISHED GRADE /-DISTRIBUTION BOX =52.25' 36"MAX. EXISTING 4" PIPE COVERS WITHIN MIN. 36" MAX. /--OVER TANK EL. as 52.25' 1 6' OF GRADE SCHEDULE 40 PVC F REMOVABLE COVER i I OF 53.00' AS SHOWN ON PLAN. MIN. SLOPE 0 2% -\.36 MAX-_ COVERS WITHIN ✓ S. _LI9*MIN.. 36"MAX. TOP 0 TRENCH 6" OF GRADE 49.66'± 00 0 0 UTILITY LOCATIONS PRIOR TO 4' PVC IN FROM j 4* PVC OUT FROM SEPTIC TANK LEACHING FACILITY. LOCUS RMAP 9.) CONTRACTOR SHALL VERIFY ALL U MINIMUM SLOPE 0 1% CONSTRUCTION THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT 1-888-DIG-SAFE AND ANY 49.50t 3'j 20-10" 29-10" 49 30=± 49.13:t E._�] LZI __71 OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES TO OUTLET TEE 4' LIQUID LEVEL TEST PIT DATA vJ BOTTOM OF TRENCH , .4� 0l-0. BOTTOM OF TRENCH TO 4 THE DESIGN ENGINEER. 1INIMUM 46,83'± -M TO BE RESET ON A LEVEL STABLE BE LEVEL EL 46.83'±' SLAB FOUNDATION BASE. FIRST TWO FEET OF OUTLET PIPES TO BE LAID LEVEL 10.) NON-SHRINK GROUT TO BE USED AT ALL POINTS WHERE PIPES -253-0$1 PERC. PERMIT NO.: 12,409 ENTER OR LEAVE ALL CONCRETE STRUCTURES IN ORDER TO PROVIDE t_0 -0 CROSS SECTION VIEW 0" -10" .3 WATER TIGHT SEALS. -10'-10" WITNESSED BY: DONNA Z. MIORANDI, R.S. END VIEW 11.) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED PERFORMED BY: STEPHEN DOYLE OR ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH SEPTIC SYSTEM PROFILE LEACHING DETAIL DETERMINATION FROM APPROPRIATE AUTHORITY. N.T.S. DATE: NOVEMBER 05, 2008 N.T.S. 12.) ALL SEPTIC SYSTEM COMPONENTS ARE BEING INSTALLED TO GROUND ELEV.: 52.25' zE WITHSTAND H-10 LOADING UNLESS UNDER PAVEMENT, DRIVES OR TRAVEL WAYS WHEREIN H-20 LOADING SHALL APPLY. ELEV. WATER: NO GW OBSERVED 13.) DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, < 2 MINI./IN. PERC. RATE: DUST AND FINES. 14.) WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL 00" 52.2'± 00. SANDY LOAM 52. AND UNSUITABLE MATERIAL BELOW AND FOR AN AREA 5 FT. ON ALL A: SANDY LOAM - 10 YR 3/2 SIDES OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL loO st 51.4'± 10 YR 3/2 06" -51.7'± WITH CLEAN COARSE SAND FREE FROM CLAY, FINES OR OTHER jBw: LOAMY SAND UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). IBw: LOAMY SAND 10 YR 4/4 10 YR 4/4 lt 15.) CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES • 36" 49.2'± 36 FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATON OF WORK. 16.) PROPOSED PROJECT IS LOCATED WITHIN: LOT#9 ASSESSORS MAP #148 LOT #8 46:5'± BOTTOM. !Cl: MEDIUM S ND i i ' OF LEACHING Cl: MEDIUM SAND i i 2.5 YR 7/4 1 17.) THIS PLAN IS TO BE USED ONLY FOR SEPTIC SYSTEM UPGRADE. I FOLD 2.5 YR 7/4 THE ENGINEER WILL NOT ASSUME ANY LIABILITY FOR THE USE OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. 87" 45.0'± C2: FINE SAND 96" --� 44.2'± 2.5 YR 7/4 C2: FINE SAND BATH t ROOM 120" 42.2' 2.5 YR 7/4 1 NO GROUNDWATER 126" 1 41.7' 48 KITCHEN DEN OBSERVED NO GROUNDWATER GARAGE OBSERVED REVISIONS: TP#1 TP#2 50 DINING LIVING ROOM ROOM LOT#8 5z DESIGN DATA: 3 BEDROOM DWELLING Oki oNow WDESIGN FLOW: 110 GP[D PER BEDROOM 1(EXISTING 1,000 GAL. SEPTIC TANK 0 BE REMAIN FIRST FLOOR 110 x 3.0 = 330 GPD (NOT TO SCALE) SEPTIC TANK: PROPOSED SEPTIC SYSTEM UPGRADE EXISTING D-BOX PREPARED FOR: TO BE REMOVED 330 GAL X 200% = 660 GALS. DESIGN CAPACITY USE EXISTING 1,000 GALLON SEPTIC TANK TOM + DIANE MCMAHON x REQUIRED LEACHING, AREA: 0 LOT#16 (330 GAL/DAY) (0.74) 446 SQ. FT. \C5 "71 C LOCATED AT: LOT#7 A) SIDEWALL CAPACITY:: 122 AMELIA WAY 25.0' (LENGTH) X 2.0' (HEIGHT) X 2 100.0 SQ. FT. 0 0 BATH BATH BEDROOM 12.83' (WIDTH) X 2.0' (HEIGHT) X 2 51.3 SO. FT. NG LEACHINGWIT ROOM ROOM ROOM fJ #1 COE PUMPED AND�-ILLED TOTAL SIDEWALL CAPACITY 151.3 SQ. FT. MARSTONS MILLS, MA. _-ITC 50 cl) BOTTOM CAPACITY: 04 CO SCALE: AS SHOWN DATE:12-03-08 310 6.0 1?0 FEET PROP. (3 HOLE) D-BOX TP #2 BEDROOM BEDROOM 25.0' (LENGTH) X 12.83' (WIDTH) 320.75 SQ. FT. - ROOM ROOM 290.51'-± ............ PROPOSED EFFECTIVE LEACHING AREA: OF M,4qS,� PREPARED BY: SIDEWALL AREA + BOTTOM AREA RoBAREA RT A. ym PROPOSED 12.83'x 25.0' LEACHING FIELD DRAKE 151 SQ. FT. + 320.75 SQ. FT. = 471.75 SO. FT. CIVIL 3- H 10,500 GALLON LEACHING TANKS WITH 4'OF STONE (471.75 SQ. FT.) x (0.74) = 349 GAL/DAY 41642 co Stephen J. Doyle and Associates • SECOND FLOOR 10 PIPE INV. 48.83' (NOT TO SCALE) 349 GALS./DAY > 330 GALL/DAY O.K. 42 Canterbury Lane E. Falmouth, MA 02536 TEL. NO. 508 540-2534 Drawn By Designed By. Checked By. 0. F�r(] I 4" 19_" 019- _7 E �\FACJI M MIN��j INL:j . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . ----------- __T ------------ T_