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0025 BARNICLE DRIVE - Health
25 Barnicle Drive Marstons Mills P / - 056 A = 057 L TOWN Oyl �ARNSTA.BLE LU^l'FIQK t n: G.-e / r. SEWAGE .ViLLA� arS ^s :�l S ASSESSORS A LOT - .II<I 3jkLI.ERlS tMAINfE&:gI flNE;NQ. SEmG'T' lqx cApACTI'k' LEr�CfIING FACII_ -fries} , fse) / /0 �� NO.-OF-BEDROOMS EU�IL�EFt."OR fl�l'rER , PI;It�TE}ATE. - ��t711�LlATdC�'I7ATla Separation d?stance Between El�c MaximuYn 11 Adjusted GroundVvater Tul le to th'Bottom bf l.eactung Fat:il�ty Fee4 Pnvate water -ply well a edlaach ;Facthty `ffl<€apy.rveils exist oca site rmithin 2€20 fit df leachi wig: facil Edg a Watland.and'Leactung£!=, Uty fIf any wet}an st within No feet cif hihj facility}_ Feet ` Furnished by � a Ro M yr _A_ TOWN OF BARNSTABLE LOCATIC`iN 25 bR*A c I Q(n"J- SEWAGE # VILLAGE AMM 4 s fyU LL S ASSESSOR'S MAP & LOT (KSAeaFv W&TAL-6EPR'S NAME& PHONE NO. AdNw*4 t1sLe4,tis 771-J? SEPTIC TANK CAPACITY /o�d LEACHING FACILITY: (type) LP_ I":24 (size) CX !O NO. OF BEDROOMS 3 BUILDER OR OWNER r.I6 n RUSEn 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 lea 'ng faS t Feet Furnished by ems— 33 .. W 5�� r 'Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bamicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 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. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation the Local Approving Authority 3-10-14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. L5. 113 Title 5 Official Inspection r ubsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � s ' 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 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: ® 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 is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ears old is available. p 9 Y ❑ Y ❑ N ❑ ND (Explain below):. t5ins•3M 3 Title 5 Official Ins don Form:Subsurface Sewage Disposal System•Page 2 of 17 r 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is'Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Official Inspec5on Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Bamicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: • 1. ❑ 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 colifofm bacteria indicates.absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into.facility or system component due to overloaded or clogged SAS or cesspool ' ❑ ® Discharge or•ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less El ® than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 7 'Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen,and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"non to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a-surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 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 M 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mill''s MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑, Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? h ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has + been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to'Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information, Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 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 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? . ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3-10-14 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? - ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 2012 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I 'Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ .Yes ® No Building Sewer(locate on site plan): Depth below grade: 12" at tank inlet 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.): Good condition. Septic Tank(locate on site plan): Err Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene- ❑ other(explain) If tank is metal list age:ge: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 '3-10-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) SepticIank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping-. Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 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 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.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3M 3 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 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ' ® leaching pits number: 1-1000 gal ❑ leaching chambers number: i ❑ 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.): Leach pit in good condition and holding water at 30" below inlet invert. No other visible stain lines. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 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 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately c„+n " ` t5ins-3/13 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 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed- Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Barnicle Dr Property Address Dave Vinal Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-14 page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r , / y DATE: - 813 /95 PROPERTY ADDRESS:--25 z.%i;,. C 4� /�.�i>;e 0..` ' i ,.,� .. ,�¢n.h.t.�n..s _ ...---- - 1 1�95 rM0FNWW ff"oEn On the above date, I inspected the septic system at the above addres This system conslsts of the following: CA 3. 1=.1000 01A..on packed in Zion-z-, Based on my Ins:�ction, I certify the following conditions: 1 , 7i,it i% .if, a t.i.i.Zelzli ,v bv_-2-t.ic '%'t 7�',n (r,,,Z S 'Codv C. d '.•016e-P't.ic bl�'bt.�.!2 l.h 4- 1120,12e?. WO,Zk ^g 92! el? >a . 'u. /2iLe64_nt I- Irzn. ,6e/21_ ,1241:n�.:e;�: 1 ' SIGNATURE: Name: J. P.M'acomber Jr.. i Company:_` .P_Macomber & Son-_Inc Address:_-8eac—bb-------A-- -- i __CentE!rvi1l,e LMass__0.2.632 Phone:__, THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MAC011RBER & SON, INC. Tanks -Lescbilelds . Pump*d & installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 77.3-3338 775-6412 a 7 Su.26m.2�¢c;e; rr'dACE DISPOSAL SYSTEM AOdress Of Property, 25 Da.zr:,.c2e Ni.v.e. Owner ' s name -c'h:.; 2u.is%o Date of Inspection 81.30,195 PART A 0 V U C K L I S T Check if the following have been done : Pumping information was requested of the owner, occupant, and Board of Health. _4Z None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and .examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _-Y- The site was inspected for signs of breakout.. All system components, Acluding the SAS , have been located on the site. -2— The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. -2— The facility owner (and occupants, if di.fferent from owner) were provided with information on the proper maintenance '.of SSDS.' e l.t.(.on..6 ?, Cove2 rho- .,Za.Z,6ee or the teach-in_g r.it. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLAW CONDITIONS. ' If residential number of bedrooms . number of current residents garbage grinder, yeas or no laundry connected to system, yes or no " seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: rgg3- �d,o6oq,L�� 7•''lOG�O i99y—�Kwom-9lS z7 7/,rtyGRV Last date of occupancy GENERAL INFORMATION Pumping recordk and source ,of information: ' 64,0 A.e,6&A 4LWt1,4&e System pumped as part of inspection, yes or no if yes, volume ;pumped _ -040 Reason for pumping: ' MAI . Type 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) Other (explain) Approximate age of .all 'components. Date installed, if known. Source of . . information:. .... _..__...__.._..._._......._.;...._-.. .. -- ._......._.....__....____..................__..._....... ... .. .._: Sewage odors detected when arriving at the site, yes or no i 9 RF SEWAGE DISPOSAL SYSTEM INSPECTION i SUBSURFACE FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: IM0 CAU&V T► AI/r( (locate on site plan) depth below grade: Ile material of construction: concrete metal FRP other(explain) dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet, invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan) N� depth of liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or.- out of box, recommendation for repairs, etc. ) / �' ' d PUMP CHAMBER: (locate on site plan) r pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, • recommendations for maintenance or repairs,etc, ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, .but may be approximated by non-intrusive methods) If not determined to be present, explain: Type.leaching pits and number l4`u Ae-e-AST &fic) ;t7 0 i&L leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, .coilditign o vegetation, recommendations for maintenance or repairs etc. ) e CESSPOOLS (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 (cesspool must be pumped as part of inspection) C� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, • condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: 11110 e . (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 • recommendations for maintenance or repairs,etc. ) . /lost/e T 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,,FORM PART B SYSTEM INFORMATION coutiaued SKETCH OF SEWAGE L_SPOSAL SYSTEM: . include ties to at least two permanent references landmarks or benchmarks locate.all wells within loo 1, Cd m AA r,U o'4 2U • i DEPTH TO GROUNDWATER . . depth to groundwater , met d 'of de cVminat ' n rnproximat Pn: i 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, or determination in,all instances "not m1nIf ` oN, or ND) . Describe basis of determined", , explain why not) O Backup of sewage into fa-cility? . Discharge or ponding of effluent to the surface. of the ground or • surface waters? _Q1(Z Static liquid level in the distribution box above outlet invert? Liquid depth in eeespeoi • <6" ume<I 12 below invert or available vol flow. / da Y 40 Required pumping 4 times or more in the last year? number of times pumped _h Septic tank is metal? cracked? structurally unsound?, substantial infiltration? substantial exfiltration? tank failure• imminent? Is any portion of the SAS, cesspool or privy: below the high. groundwater elevation? 11L within 50 feet - of a surface water? within 100 feet of a-. surface water supply or tributary to a surface water supply? _Q within a Zone I -of a public well? ..&Q within 50 feet of a bordering vegetated wetland or salt marsh- (cesspools and privies only, not the SAS) ? ' _&e_-- within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has •been analyzed to be acceptable, attach copy of well water an �for coliform bacteria,. volatile organic compqunds, ammonia nit 4 and nitrate nitrogen.. rogen TOWN OF Bret,-2 iIt z9.e a BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION F•••�r•t •:-::+-rfr.:-.--nrr. •r.:rrr—+s•.—r.-*-rr-r-r.•rem:r.T.-e:rn-rr'r'nrns•+.�rr._-rrrrrm-e-a3 no a.mnmmrr-rrr •rsaVerrr"r..e-nr•r.•-:••-•. -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS ?'i ill as?,. ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME loha ?u _40 • PART D - CERTIFICATION I NAME OF INSPECTOR ?.. 8,7,c om:'en_ I:r., COMPANY NAME i.Mac.o.mg<%IL f .Son .Inc.. COMPANY ADDRESS Box 66 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 i 775 - 3738 FAX ( 538 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate, and complete as of the time of inspection .. The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems. Check one: .XXXX.X System PASSED Tile inspection which -I have conducted has not found any information which indicates that the system fails to adequately protect public health or tile. environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which Ihave conducted has found that the system fails to protect the public health and - the environment in accordance with Title. 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature le I V Date 813'01 95 One copy of this c tification must be provided to the OWNER, the BUYER (where applicable and the BOARD OF HEALTH. * If .the inspection FAILED, ' the owner or�� p operator shall u P pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doe C:n;rrcnweacn cr Mas =---secs Execuive Ot►ice cr Env omnenic, Department of Environmental Protection ' Wo'rer Pollution CcnTrol Tewniccl Assocnce ana Training Sections WIWam F.WOW Trudy Co:• 560-Y.WEA • Thomas&Paw+rs • aar+q comnn.uon. . 06/12/95 ATTN: Joseph P. Macomber, Jr. .. Joseph Macomber and San PO Box 66 Centerville, MA 02632)- Dear Joseph P. Macomber, Jr. ,,' I am pleased to inform you chat you have attended training, met the experience qualificacions, Iand have passed the Title 5 System Inspector exam, pursuant to 310 CMR. 15.340. The passing grade for the exam was 39/52 or 75%. This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15.340. You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address: Kimball Simpson U.E.P. Training Center 50 Route 20 Millbury, MA 01527 Thank you very much for you:: time and consideration in this matter. Sincerely, /r Kimball ':. Simpson, DEP Training Director [2405) Routs :'0. • Millbury, MA r,• , • FAX 508-755.9= • rp...none 506.756.7701 Water* ., Conservation SAVE Ti S . ME! p CHECK FOR LEAKS Water.Loss in Gallons Due to Leaks Leak this Loss?er DayF20, Size120300693 • 1,200 36,000 1,920 57,600 3,096. 92,880 .0 4,296 128,980 ® 6:640 199,200 ; 6,984 200,520 ® 8,424 252,72.0 9,888 296,640 11,-324 339,720 12,720 381,600 14,952 448,560 i ............ THE COMMONWEALTH OF MASSACHUSETTS go ROB ti BOAR® Off' HEALTH N l 0 19 75 Q\f ..__.................OF... 11.. j-.....-•---.........._...-•=-......... 'N L���`��� .�pplira#ion for Mipviial Works Tawitrurtiun amit a �� Application is hereby made for a Permit to Construct ( Lor Repair ( ) an Individual Sewage Disposal System at: Lc-r 6o -- _ 1 1. L.� .....................................•------...---'--..•.•.•.....---------•-----....-- 1,, Location Address or Lo�/N�.L1 ....... N h..7_L, �.� ................................................... :�.}}..w_f7 Own 1tress MA Installer Address UType of Building Size Lot___ ...Sq. feet Dwelling—No. of Bedrooms...............-5........................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria PaOther fixtures -------------------------------------------------------------------------------------------------------------------------------•-----------•-•------- Design Flow.............55........................gallons per person per day. Total daily Qow.............. ..................gallons WSeptic Tank—Liquid capacity.�0-Q-.gallons Length.16�-��t. Width_!7�'.... Diameter................ Depth_fa�_:3[�. x Disposal Trench—No..................... Width................... Total Length.................... Total leaching area_._..._______...... fY. 3 Seepage Pit No.___.�.............. Diameter---- Depth below inlet.................... Total leaching area_ 2- .___.._stt. Z Other Distribution box � Dosing tank ( ) `-' Percolation Test Results Performed by_,RR I_-___ .: C_NC-------- Date....:-L Zest Pit No: I........ ...._.minutes per inch Depth of Test Pit----- ..... Depth to ground water..A.)nu-C---E UoT; Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -��� �C------ -- --I. .. . . ..............•- - it- ��.......L_.........-- -- ------ • -- ---•-------•----I.......... Des r n of Soil ( Tom,?.��.. d .s o P C_J ��-----...... ��_..CO�4 U� �a�Jd2•.� cxi ------------------------------•---•-----•--•---......--•-•-......•- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••--••-- U Nature of Repairs or Alterations—Answer when applicable.................................................................................__..........._. -----------------------------------•------------------------------------------------------•---......-•-•-••--•-•••-•-•-----------•-----•--••-•-•--•-................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT=% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed-- --•-•--•••-•-•--•---•--••--•---••-•------•--•---•-•---•--•---••--••-•--•••---- Application Approved ....• refollowing -----=------------------------------------ Date Application Disapproved r reasons:................................................................................................................ ..-------•-----------------------------------------------•--•----------•-----------.....----•-------...--------•-----•-••-•---•------••--•-•-•--••-------------••--••••----•-•-•----•-•......---•-••---- Date PermitNo......................................................... Issued-....................................................... ., fG r F�$..... . �i............. THE COMMONWEALTH OF MASSACHUSETTS a° R BOARD OF HEALTH 1 98 tii ...................OF.:.... �.... -.. ppliration for Biapoiittl Morkii Tonitrnrtion Vamit /ONAL pplication is hereby made for a Permit to Construct ( 17-or Repair ( ) an Individual Sewage Disposal System at ..._ '??���.�-i c T.�-.... ................................ ....._...____...--•--.....-•-•-�'•-c i.'•_.�. ................ - _•__.....------..... .... q Location-Address r Lo N , t _ � `�- -------------- ...-.........----...---..... ..........._ ......V�_i 4_ -(`�q ...... �m ...................4 ............. yy-•-•--- �''s-w `-t'=-y--5 -ddress '�'"'.1' Installer Address UType of Building Size Lot_____R� _¢-'�___Sq. feet Dwelling—No. of Bedrooms_______________ ________________________Expansion Attic ( ) Garbage Grinder ( ) aa4 Other—T e of Building No. of ersons____________________________ Showers YP g ---------------------------- P (--->--- Cafeteria ( ) Otherfixtures ---------------------------------•-•-•••--- -•----...--•••••---•-••--------••---------------•-----•••••-;.:- ....._____ W Design Flow............ " ________________________gallons per person per day. Total dui,l�??''Fiow.__.._.__.___�_�?.�...................golons. GG Septic Tank—Liquid capacity_0 Q_gallons Lengthy�F`. ___ Width. ?_c.i ___. Diameter________________ Depth_ ... .. W Disposal Trench—No- . _. Width__________________ Total Length.................... Total leaching area... 3 Seepage Pit No_____ ______________ Diameter___ ..:_ ___._. Depth below in-let.................... Total leaching area_.__.________..._s . Z Other Distribution box Dosin tank ( ) ~' Percolation Test Results" Performed by-- 11 .-�46 �5�_ �' � .:.�c_._.___.. Date_. �___. E__�� 3 a --••-- Test Pit No. I.........: .___minutes per inch Depth of Test Pit______ ______. Depth to ground water a w •}.: G 5 (s, Test Pit No. 2.........._.....minutes per inch Depth of Test Pit_________.__________ Depth to ground water........................ O , a .... -- De. ri tion of Soil__:._--.. ........ _. f,►a............... � •--1 r S -- ,a -- ......... 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 '1T t'<�:the provisions of!:: _ �: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by.the board of health. Signed.- - = ....................-•-----•-----•----•-"-•-----••-•------------ ----- Date Application Approve =f l --- ate Application Disapprove or he following reasons---------------------•--------•---------•----••-•----•------................................................... ••_______________•-••-_______----•--"---••--•----••••--•-•------__.-----•-----------•-•"•-••••---•-•""-............................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Qrrtifiratr of Tong hattrr T#fS IS T .CERTIFY, That the Individual Sewage isposal System constructed or Repaired ( ) .�'`• / -'- ost er Z----------------------- has been installed in accordance with the provisions of I I`I; j of The State Sanitary C e. escribed in the application for Disposal W'Orks Construction Permit Ney-t-I&.___________________ , datef !_ __ ��_._._._.______..______._ THE ISSU NC - OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS GUARANTEE THAT THE SYSTEM I F fCTION SATISFACTORY. DATE... 7 ..Q..l-- Inspector .•---•---••--•"•-----------------•---•-----------•"--•--•••-----•---......_------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........�� ............ .....0F...... ENA ...._.....�'a�_9_ I - . ...:_....... No .......... . ..... FE> ................ Mops lugr •g wonotr ion Can it Permission is hereby granted_ . i - _:_._._ ( �Cf -••---1--•P----•-••--y-------•••-•••--•=••-••••-•-•-••••-••••---•----•••........................... to Construct e�air an Indiv al Se e Disposal System atNo........ �o, ��r2.=. L ;r ......--•----•---Street-----....•-------•----^---•-•--.._..--•-------•.................................. as shown on the applicafton for Disposal Works Construction Permit No ________ ________ Dated.......................................... eZlJj•------•--_____••••---_..----•----••-•--_......... Board of Health DATE....--.---------------= . f FORK 1255 HOBBS & WARREN. INC., PUBLISHERS DPAWN BY _ -_ ___-_. ._ tom{-��� ' � �JaS6✓l!� 3�cc� wlrNl-+wtrL z yam..c-vx�c.�t-ic e¢. �+ II s�•�(s'c��s�vcNcs _ rovcrcN GfLI-i_ /y _S/ L- 7J^Rf'op('ITck r1TIWNpw+� ��• ,A�� _s.Ilrwlrs xz#�.,uI Nil I sz _BLZ�t.W�'!L C Ncrosl� I I 111111 T �1 I- - Qo�N XY3I0 J4°ilo j= �oo.�+c wu�j wnt errs _--ay. �.-._-_•___.-. 4 - -_ FRONT ELEVATION RIGHT ELEVATION i NOTE: • 0 i4 yy ti_g t±UN V-�U�IS�SE•CBIKKI'G j a,cy�w•iu-s- ;� A a �--"1 '- - '--- c eC -- ----_ Ci _ st STING.R>=5•oE+IC-c+ T F1lnTI"rWOlL� _. .. -- roE eAo oorn F�a-pt1mg66• rle ----'---- _—_ ..�-'-- - - -- ""_--- - EYISTiNb REAR ELEVATION "J ', IArRETc te fP+.v- y ''r�nOa � I CW'!<oF GaiuG � ERKK ePf N 1 (� - � pRetAO</�SWOOTa�NT. 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