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HomeMy WebLinkAbout0155 BAXTERS NECK ROAD - Health W155 Baxter Neck Road Mafstonslvmls ,A = 07.E — 001 —X03 ti . -- � Commonwealth of Massachusetts o� - apt 03 P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 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 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the,time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12/2/20 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does-not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owners Name information is required for every Marstons Mills MA 02648 12/2/20 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .� 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments fV t 9w'1; 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 page. Cityrrown 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.7/2 612 01 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 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 Y2 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 II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coot.) 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? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: 4 bedroom permit and engineered plan on file Number of current residents: 5 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 260 GPD 9 ( Y 9 (gP ))� 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 r . Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 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: No recent pumping 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.7/26/2018 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 L 155 Baxter Neck Rd. Property Address O'Toole Owner Owner s Name information is required for every Marstons Mills MA 02648 12/2/20 page. Cityr'Fown 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: 1998 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'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 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete El metal ❑ fiberglass ❑ polyethylene El other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle '12 Scum thickness 4" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2" 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 (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 page. Cityfrown 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 Y 155 Baxter Neck Rd. Property Address O'Toole Owner information is Owner's Name required for every Marstons Mills MA 02648 12/2/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 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 12"below grade, no adverse conditions observed t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 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: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner s Name information is required for every Marstons Mills MA 02648 12/2/20 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 are end loaded, they were video inspected, effluent is 12" below the invert at this time, no indication of past hydraulic failure, top of chamber is 30" below grade 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 r Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 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 Commonwealth of Massachusetts �. (e 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 page. Cityrrown 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 2 � 1 "U:::J�:�c �- l � 1 l � Ott A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •v, 155 Baxter Neck Rd. Property Address O'Toole Owner Owner's Name information is required for every Marstons Mills MA 02648 12/2/20 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: >132" 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: 1998 NGW 132" Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 1998 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 38'msl and nearby surface water at 2'msl You must describe how you established the high ground water elevation: See above 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 I f Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 Baxter Neck Rd. Property Address O'Toole Owner formation is Owner's Name required for every Marstons Mills MA 02648 12/2/20 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 •71U"OF BARNSTABLE LOCATION ST N�k SEWAGE # 9-ff 0 f �t T� VILLA �Qr�lanJ /fi. ASSESSOR'S MAP & LOT G 7S X e 1 INSTALLER'S NAME&PHONE NO. &Aey Sr SEPTIC.TANK CAPACITY knx LEACHING FACILITY: (type) w (size) 4 - NO.OF BEDROOMS 3 BUILDER QR OWNER) PERMITDATE: W-/2 -2 h 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching fac ty) Feet. Furnished by i i I a a „7)Th /A , 101 ' a TOWN OF BARNSTABLE Y r LOCATION 13Y 9!&rer Veek SEWAGE # 95 -&-0 VILLAGE ASSESSOR'S MAP & LOT G I • X ®7_ INSTALLER'S NAME&PHONE NO.leek eoastr- /k :1-4- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) WOW (size)( NO.OF BEDROOMS �e dAo�jY`�1 -��e•,.� .(1l s��y v BUILDER OWNER \�v� PERMITDATE: �f-l2 cf rY 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 a Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facity)� Feet. Furnished by tq no. �J � THE COMMONWEAILT OF MASSACHUSETTS FEE t. BOAR OF HEALTH OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (,JJ/Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components t'�L577SP_ i 55 �,4-��t_ ��,�,�• c�.o Location Owner's Name Map �5 pGt im r c�� 1 ubl b2. Map/P u J# Address Lot# Tcic ;c# ` 7 Installer's Name Designers N c Address Address Telephone# Telephone# Type of Building: Lot Siz Sq.feet Dwelling—No.of Bedrooms �4 r Garbage Grinder ( ,.) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow min.required) 155 . gpd Calculated design flow4�gpd Design flow provided gpd Plan: Date `(o- Number of sheets �_ Revision Date Title Descripti of Soils �6 l� - 17" Soil Evaluator Form No. Name of Soil Evaluator'7 Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu r agr snot to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed t�J Date Lf t� -it Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 THE GOMMONWEA'71'OF MASSACHUSETTS FEE ��/ � tip .. BOAR O F '`H E A,LT H . OF + >, r s APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (Repair ( ') Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components 155 -hA tJQ.c d - a o Ll tr Location A Owner's Name (Yi 5 PSt 4 c f DCLL Map/pl c N Address •� �' Lot# Telephone# t Q l Ll Installer's Name Designer's N49 c h t Address x Address Telephone It t Telephone# ) Type of Building: t }.r Lot Siz rA �:.. . Sq feet Dwelling,—N�o.of Be• ooms'. r Garbage Grider Outer—Type of Building p No.of persons}�°0 Showers.( ), Cafeteria -( Other fixtures - r ,Design Flow min.required); �rJ gpd Calculated design flow A4K'�> gpd Design flow provided"1(03 gpd Plan: Date 3-(e-9tQ-> _ Number of sheets Revision Date l Titlee�a'o o4a& c cr _ Descripti of Soils = • Sn �� (," IB"24d � _ 't —13Z' �tg d , Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation a 13 DESCRIPTION OF REPAIRS OR ALTERATIONS f Z The undersigned agrees to install the'above described Individual Sewage Disposal System in accordance with the pro"visions of ' TITLE 5 and furtherag snot to place�e system in_,operation until a Certificate of Compliance Fias been issued by the Board of Health. Signed e� Date '-1� 19� Inspections 00r151r � I n FORM I - APPLICATION Fd11,DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE 'XIev„0,3 BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) oe at has been installed in accordance ith the provisions of 310 CMR 15.00 Title 5) and t e approved design plans/as-built plans relating to application No. dated ' s , Approved Design Flow ' (gpd) 1 I Installer Designer: Inspector // Date his 1 The issuance of t certificate shall not be construed as a guaranfiee that the system will function as designed. it FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 NA; �/ THE COMM;ONWEA�LT:H OF MASSACHUS FEE ETTS �.. � j. BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to'Construct (0--�Repair ( ) Upgrade ( Abandon ( ) a individual sewage disposal system at f s described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be/completed within three years of the date ofthis pertD40 All loca conditions must be met. t `n � � 4r/ ' " Date Board of Health " FOR14:2 - DSCP DEP APPROVED FORM 5/96 „-FORM 1255 (REV 5/96) c H&W 11088S8 WA♦3REN'" PUBLISHERS- BOSTON I PAR ] Real Estate System - General Property Inquiry] Help [ ] A' Parcel Id: 075 001-T01- Account No: 38738 Parent : Location: OLD POST RD COT Neighborhood: 28AA Fire Dist : CO Devel Lot : Lot Size : 18 . 00 Acres Current Own: AMMEN, IRVIN G State Class : 101 .WORCTYNTNL BNK .HENNIGAN No. Bldgs : Area: 446 MAIN ST Year Added: WORCESTER MA 1608 Deed Date : Reference : C1140 January 1st : AMMEN, IRVIN G Deed MMDD: 0000 Deed Ref : C1140 Comments : Values : Land: 443800 Buildings : Extra Features : Road System: 1075 Index: 83 (BAXTERS NECK ROAD ) Frntg: Index: ( ) Frntg: Control Info: Last Auto Upd: 092196 Status : D Last TACS Update : 051888 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : THIS PARCEL IS IN-ACTIVE Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [075] (001] [XO1] [ ] [ ] PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 075 001-T01- Account No: 38738 Parent : Location: OLD POST RD COT Neighborhood: 28AA Fire Dist : CO Devel Lot : Lot Size : 18 . 00 Acres Current Own: AMMEN, IRVIN G State Class : 101 %WORCTYNTNL BNK %HENNIGAN No. Bldgs : Area: 446 MAIN ST Year Added: WORCESTER MA 1608 Deed Date : Reference : C1140 January 1st : AMMEN, IRVIN G Deed MMDD: 0000 Deed Ref : C1140 Comments : Values : Land: 443800 Buildings : Extra Features : Road System: 1075 Index: 83 (BAXTERS NECK ROAD ) Frntg: Index: ( ) Frntg: Control Info: Last Auto Upd: 092196 Status : D Last TACS Update : 051888 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : THIS PARCEL IS IN-ACTIVE Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [075] [001] [X01] [ ] [ ] A �. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address gree; &, Owner Owner's Name /) /f`Q information is A f//%� _✓ �� /.S 11,9 Qx T O _ required for ___ — S every page. City/Town State Zip Code Date of Insp ction Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information ill forms on the ��J(22 computer,use 1. Inspector: (� only the tab keyVj to move your a y k/ cursor-do not Name of Inspector - , --� use the return Z y �v O _ ;�G 4 C key. _ ._ _�_I/ G 1/ ompany Name Company Address City/Town (s State Zip Code tag) 17�b/—- 2 �zf Telephone Nunlb6r 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.] am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails � o ❑ Needs Further Evaluation by the Local Approving Authority : Z Inspector's Signatu Date The system inspector shall submit a copy of this inspection report to the Approvi g Authority(Boa d of Health or DEP)within 30 days of completing this inspection. If the system is shared system v has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submli they 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. U0 v� t5ins•11/10 M 5 oftlal In o F :Subs rho Sewape DlapoaaI System• 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal S stem Form-Not for Voluntary Assessments Property Address lyre 4 4 Owner Owner's Name information is A.Is''�b✓I S �� t / Q.,16 Wrequired for _______ .—_ — every page. City/Town State Zip Code Date 6f Inspi6ction B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 7have1notasses: 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: S) 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 approve_d by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11H0 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sydam•Pape 2 of 17 _f,\' Commonwealth of Massachusetts xMENEMTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G�(�e✓ /1/e c� it Property Address Owner Owner's Name _�/ information is .- ,� ��' s `/ Qp26 qY �/ p�vci arequired for - �� State Zip Code Date Insn every page. City/Town B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 151ns•11/10 Me S Official InspooWn Form:Subsurraea Sowapa Disposal Sysfom•Papa 3 0117 I i Commonwealth of Massachusetts Q. a U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 19 ISS, Property Address Owner Owner's Name /� information is / ' l"4o hs lle/l/S A14 Q)C((";-2 required for every page. Cityfrown State Zip Code Dat of Inspiection 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 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 P system asses if the well water analysis, performed at a DEP certified laboratory, for fecal Y coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No j ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ina•11H o 7ltle 5 Oftel InspeoBon Form:Subsudeoe Sowpe Dlsposel System•Pope 4 of 17 II - <tN' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address le a Owner Owner shame /� /�© information is required for �! `__ _—_--___ _ L �L Zip Code Date f I on_, every page. Cityfrown State p nsp B. Certification (cunt.) 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. i ❑ ff Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ [El--- 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 ❑ l'� will. ❑ l Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a rivate water supplywell with no acceptable water quality analysis. [This p 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. ❑ Er The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed 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. t51ns•11110 Too s oftisi fnspecdon Form:SubUftee Sewspe DO MI SyMem•Pepe 5 of 1 T 1 N Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _ _1l ec Property Address Owner Owner s Name information is � '�f _A ro required for I --- every page. CityfTown State Zip Code Date o nspe on C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ Ef"'� 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 NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: / Number of bedrooms(design): Number of bedrooms (actual): ,` DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ��� 00 V1 P,01111M I —/60 Sns 11110 Title 5 Of lal Inspeckn Form:Sutnufto SwAW Dlsposel System•PW 0 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address leer 14 _ Owner Owner's Name / information is _ � '' /� 4 Deb-6 qy 1140147 required for -- A/ /� every page. Clry/rown State Zip Code Dat4 of Ins ctbn D. System Information Description: /SOO _. _ ��1100 s;a4c t a 1 , _�_� ._�o� 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes o Is laundry on a separate sewage system? (if yes separate inspection required) ❑ Yes 0"'No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes J2�io Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑`Y No Last date of occupancy: 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/personslsq.ft., etc.): - -- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ----- __ t5ins-11/10 Title 5 Official Inspection Form:Subsurface$swaps Disposal system•Pape 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form•Not for Voluntary Assessments led Property Address Owner information is Owners Name ors l o5 A As- A 0-4qS // oli� required for — —•-•--- every page. City/Town State Zip Code Date o Inspe on D. System Information (cont.) Last date of occupancy/use: pate Other(describe below): General Information Pumping Records: 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 tem: 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•1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposel System•Page 8 of 17 r ' Commonwealth of Massachusetts Title 5 Official p' I Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name / Al"XTf, �A0d/(/,ginformation is �p KS /f b o Oc required for "--"— State Zip Code Date 0 Inspe on every page. City/Town �...� ._� D. System Information (cunt.) Approximate age of all components, date ins ailed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 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 Materi of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No � X /O Dimensions: Sludge depth: 151ns•11/10 Title 5 Official Inspection Form:subsudace Sewage Disposal Sysiam•Papa 9 o/17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address _... et,-e --- owner Owner s hams — / S ^/////� ado 7� �� p�p loZ information is Gaffs �S -- every for — State Zip Code Dat of I ction every page. City/Town D. System Information (cont.) Septic Tank (cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness -- A/ Distance from top of scum to top of outlet tee or baffle - - Distance from bottom of scum to bottom of outlet tee or baffle -- How were dimensions determined? -" --- - --' Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �(AI 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: Nns•11/10 Title 5 Dffklal inspection Form:subsurrece sowage Disposal syalom•Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner OwnersName�/ information is 0,2 4�O 4N � AInspe ��required for — every page. CityrrownState ZipGode on 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 t51n3•11/10 Title 8 Official Inspecdon Form:Subsurface Sewage Disposal System-Page 11 of 17 a _ f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name- Information is required for - �._. _ _._ o Ad, every page, CNy/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on�site ,pllan): Depth of liquid level above outlet invertv L- -- --------— - 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ttflns•1 Wo Tide 5 ORblal Inspadlon Form:Subsurtwo S"We 04"Syabm•Pape 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address �e G to _ _ --- Owner Owner's Name information is Gr�S 7�I✓1S //�/� /�j� D�p required for every page. Citylrown State Zip Coda DateVC�spoaon — D. System Information (cunt.) Type oo ❑ leaching pits number: ❑ 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.): 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 t51ns-11/10 Title 6 Official Inspochon Form:Subsurface Sowope 0sposal Syst m Pop 13 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments --as —12e'? Itle-c,k, Property Address Owner Owner's Name 1 Information Is / t,rS7�/!s ���� required for _ — every page. City/Town State Zip Code Date o nspe on 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.): cs��g•�v�o �� ��r+ ^r�nm:ssim�I�at14ti6Afi� � � I Commonwealth of Massachusetts MEN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Sax-�r /'(Zc c l✓ e1 Le Property Addressi L4 - Owner Owne►'s Name ) O required anon Is G s 0✓t s 11 0d �o— / lolo lO� required for _•- - every page. CityrTown State Zip Code Date 90 In5pe6tion 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 whet ublic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately LA � G I Co Vet 30 t Yr 14 3 G1 - r3 I in•11n0 TMe 6 Oftiai inspection Form:Substafece Sewage Dbposai System Papa 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments /55 . _ -�e� /C/ec k Property Address Ole Owner owner's Name - �. — information is �_a✓S�0 n _/-r- �� 06�f l� a t required for every page. Clty/Town State Zip Code Date Inspedbon D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: lQ✓IS -/- 7e-s� hole ._-=---- ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must de be hgw you established the high ground water elevation: 45 Before filing this Inspection Report, please see Report Completeness Checklist on next page. thine•11/10 Tide 5 Of el Inspecdon Form;Subsurface Sewage Dlaposal System•pap 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner Owner's Name Information is /� required for // /7 every page. CityrFown State Zip Code Dat of Ins ection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed m Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5lns•11/10 Tltle 5 Official Inspecibn Form:Subsurface Sewage Olsposal System•Pop 17 or 17 i i ����. .� ,r :� S YS TEM PROFIL E NOT TO SCALE TOP FNON. FINISH GRADE �r o „ �- FINISH GRADE OVER EL . T.5'; a OVER TRENCHES ,,. FINISH GRADE 7y- FINISH GRADE OVER DIST. BOX 9 0 f'° SEPTIC TANK �. Q�6 12" MAX. a e: �, a ..�,,.b. �oa•.ep..�?;?e'::Q.e�p•0. o,o,.a ti'a. ::.•. .e•. b.•.� i b TO TA L ENGTH OF TRENCH o,o.P. �• OUTLET PIPE LEVEL 3„ FOR 2 FT. MIN. •mod,:�• a� 6• G82.� G�; �'.:a e: :a::l:e' ? " ' CAP END oeo C. I. OR PVC TEES 68,0o G7.5�o G68o o 10 L� O O O O [� bEL$ e p ''•:d.r'C.• D• ------�__-- '�1'ems _ .�y�s�/c -•-�-•� g I I I I P ro 1500 GA L L ON b DISTRIBUTION- BOX y BSMT FL . a •q•p • EL . G 7- S o.a o �� INS TALL ON LEVEL BASE "500 GALLON DR YWEL L S " ° PRECAST CONCRETE b H -1 D _ REINFORCED a• ao ��ao:as�.t:a•.b' 'e:•n•'b:r0 ',Q.o;e.�`..• pp•p.p. ...e.,.e. .. �• • :' �.•o..v`,eo. �' .a,e �::D..s:;�• .o,p.P p,o,a�"a .•4.Y.op7?P. —� SEPTIC TANK TRENCH SECTION INSTALL ON LEVEL BASE NOTE.' EXCAVATE TO ELEV. OR �7,oa LOWER TO REMOVE ALL IMPERVIOUS *,,r MA TERIAL BENEA TH THE LEACHING AF?EA 4. DIAM• 12" MIN- REPLACE EXCA VA TED MATERIAL NI TH 3" OF 1/8"-1 j2"' z� CLEAN, CLA Y FREE SAND ° 04 o A i. W A NA PE STONE 4*6 1 �o a ,:/4 - 1-1/2" WASHED CRUSHED S TONE GENERA L NOTES TRENCH WIDTH ' ('70 y 1. ALL EL EVA TIO,".`S SHOWN ARE BASED ON ASSUMED NUMBER OF TRENCHES 1 ( y I 2. ALL PIPES IN THE S YSTEM MUST BE CAS T IRON NUMBER OF DRYWEL L S 3 OR SCHEDULE 40 PVC. -wc 7E, �i I� 'r rr)#FI . 1./IJa�t_t t r A _ I I --4— 3. THE BOARD OF HEAL TH MUST BE NO `d o' s` IrH�� ����` WHEN CONSTRUCTION IS COMPLETE PRIOR BAXTER 6 NYE • �P � ,-� I i r�� . e A .c za PERCOL A TION RATE.' r �a fl' e - c'i TO BA CKFIL L ING 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED <2 MIN./IN. BY THE BOARD OF HEAL TH AND CAPE 6 ISLANDS WITNESSED BY.' IN,\ ��� ;' so'� i SURVEYING CO., INC. ✓ERRY DUNNING 5. MATERIALS AND INSTALLATION SHALL BE IN B,�:RNSTABLEBRD. OF HEAL TH DESIGN DA TA COMPLIANCE WITH THE STA TE SANITARY A T FEB. 12, 1998 CODE - TITLE V - AND LOCAL APPLICABLE D E. _ _ _ _ _ _ RULES AND REGULATIONS NUMBER OF BEDROOMS 4 6. NORTH ARROW IS FROM RECORD PLANS AND NO IS NOT TO BE USED FOR SOLAR PURPOSES ��� " o GARBA GE DISPOSAL . ^� -��,. ��,., � DAILY FLOW 440 GAL . 7. .FL 000 HAZARD ZONE C (NON-HAZARD) ���� - o�►M- - u v ��' TOWN WA TER -8 . s�^�+ �- -�. °Y 2 s/� SEPTIC TANK RECJ 'D. 1500 GAL . Zvi I �n b I �e� �Z 8. NA TER SUPPLY ,dr Y _ Zz� SEPTIC TANK PROVIDED 1500 GAL . 440 LEACHING REOUIRED GPD. ->e) 7d __- � � 12p 2 J � �1 ul u r•, -S•R r.c� SIDEWAL L AREA = 186.S. F. .,` ,--' ' 1B6S.F. X O '4G/S.F. = 132 GPD. 7/3 BOTTOM AREA S. F. _z s LEGEND 7 z 463 441 s.F.X 0. 74G/S.F. = 236 GPD j �� / �`s'� �•o / i �cc �.: .__ E-�s_c, LEACHING PROVIDED GPD I C 7 r.�q PROPOSED ELEVA TION �� o) -�?. -�z ��'s'•'s'� EXISTING CONTOUR SINGLE FAMILY RESIDENCE & os�� 1_ � ® OBSERVATION PI T 0 DISTRIBUTION BOX p� �o A l I; PROPOSED SEWAGE DISPOSAL S YS TEM MCI ARD yam, r \ J r, m ' s --- i iRIAND ' per;` ;"" u PREPARED FOR ro—o-1 SEPTIC TANK �s �oN ,�� DOUGL A S WIL L IA MS 10 HOUSE 155 (L O T 11) BA X TER NECK RD. __ _ _ �`" __c'..��. __ .�.,.�•,� — —� RESERVE AREA — — ��" °F y ` MARS TONS MILL S—BARNS TABLE—MA SS. �� DAvl� �r �B Z PIPE INVERT ELEVATIONCHARLES SANICKI DA ' 26M CAPE 6 ISLANDS ENGINEERING 2 30 PLOT PLAN " STEM SCAL E A S NO TED 133 FAL MOUTH ROAD - SUITE 2E SCALE.• 1 ~*e .'z/O� 7j .X a� �� /S.�"� "AND MASHPEE, MASS.PLAN NO.•SG3aG 98 5 MAP SEC PCL LOT HSE '