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Home My WebLink About0505 BAXTERS NECK ROAD - Health 505 BAXTER NECK - --- - - -- -- MARSTONS MILLS � A = 075 007 9 ;r Commonwealth of Massachusetts 0�� 00 9 �r R. Title 5 Official Inspection Form Subsurface System Disposal Sewage Dis g p y tem Form Not for Voluntary Assessments J/ 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 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. filling n A. Inspector Information ( -W j� 113 fillin out forms on the computer, 'Use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return Company Name key. 350 Main Company Company Address W Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 SI-14423 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 1/18/2021 inspector's' I re re 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 i, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 BAXTERS NECK RD V Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or.in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM IS IN WORKING CONDITION 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): l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 BAXTERS NECK RD V Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 151nsp doc•rev 7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 118 Commonwealth of Massachusetts �r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 505 BAXTERS NECK RD,- Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water'supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 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 I ' Commonwealth of Massachusetts 61A Title 5 Official Inspection Form Yip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any.question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts 1►= Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 BAX_TERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 pace. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: 2 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 [I Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2020-1,100,000 GALLONS 2019-857,000 GALLONS. JACUZZI & POOL LOCATED ONSITE Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 r ti . Commonwealth of Massachusetts lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is _ required for every MARSTONS MILLS _ MA 02648 1/15/2021 page. City/Town 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? El 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: N/A 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 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTON_S_MILLS_ MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil Y absorption system P ❑ 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: 2000 PER ASBUILT ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 14"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 104 feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts i,(z� Title 5 Official Inspection Form j. I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is every MARSTONS MILLS required for eve MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 4"feet Material 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 Dimensions: 1500 GALLON 2" 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 How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 4" BELOW GRADE t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I Commonwealth of Massachusetts ,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 BAXTERS NECK RD v` Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 _ page. City/Town 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.): B. 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f 4-�;\ Commonwealth of Massachusetts p Title 5 Official Inspection Form Di S f Subsurace Sewage Disposal System Form - Not for Voluntary ry Assessments 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is MARSTONS MILLS MA 02648 .1/15/2021 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ 'No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EVEN 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT r l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts =i ,(i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Nane information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: 5-500 GALLON ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑I innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 II Commonwealth of Massachusetts Title 5 Official Inspection Form Ic Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a. � 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 5-500 GALLON CHAMBERS FOUND DRY DURING INSPECTION WITH VERY LITTLE PUDDLING. NO EVIDENT STAINING 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.): l5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I I Commonwealth of Massachusetts Title 5 Official Inspection Form is, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTO'VS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) f 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.): 15insp doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 ' 1/15/2021 page. City/Town' State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately M 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts i-- , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10'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 sitea(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: HAND AUGER PERFORMED ONSITE TO 10'3" ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 52". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I� ' r Commonwealth of M, assachusetts p Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - u;/� 505 BAXTERS NECK RD Property Address DAVID BERNARD Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 1/15/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: 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 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 14 3 ! '6�'' � 1 C� F03 TOWN OF BARNSTABLE V op l glmllwo LOCATION1 )5 C , = SEWAVE # '7* ra--7yZ VILLAGE Ne'll ASSESSOR'S MAP & LOT Or—''�7aY INSTALLER'S NAME&PHONE NO. /` '�� 7' �� 5 7 T/-"- �p-'�_ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) S7 C�"l IM l' - - (size) S CD�� NO. OF BEDROOMS UII..DER R OWNER �vGS PERMITDATE: —Z 2 ()D COMPLIANCE DATE: 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ,on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 14 p 2- 6 y,s-,, -- i�a, -; t No. O ,9 FEE COMMONWEALTH OF MASSACHUSETTS L,� Board of Health, : J 7 4 e,C , MA. IATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Applicatio for ermit to Co struct Repair( ) Upgrade( Abandon( - 'Complete System ❑Individual Components Location / ' Owner's Name Map/Parcel# 'fs c — Address /�,Ld' �L�{p�� /)� / %//-PeL- Lot# M MTelephone# X3 .3 >l'7-,73 Installer's Name 49,0,//p � ��-/ o Y, Designer's Name Address /}%y,f „S ✓��`��f i+91 Address 6T, Telephone# 7 7 '� Telephone# �s� - Type of Building Lot Size S sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) e A- gpd Calculated design flow d7�� Design flow provided gpd Plan: Date �� Number of sheets Revision Date Title/S6z��r -A, ��/�l�✓✓� / Description of Soil(s) ® 2,!jY -��/°��T1�� J o L� )W Soil Evaluator Form No. Name of Soil Evaluator Pate of Evaluation FF 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 further agrees t not to ceke system in operation until a Certificate of Con)pliancg has been issued by the Board of Health. Signed Date 0 TOWN OF BARNSTABLE ----- LOCATION _r5 OS`y�a.1' ✓'rI�G, �' SEWAGE # VILLAGE re)7�L(/?� ASSESSOR'S MAP & LOT �✓�`�� INSTALLER'S NAME&PHONE NO. rLe. 5 eO115�` 7?/`9,3y SEPTIC TANK.CAPACITY LEACHING FACILITY: (type) _S r�'1C�OA (size) _S^Cl) NO. OF BEDROOMS _ UII.DER R OWNER PERMITDATE: COMPLIANCE DATE: O+ Q0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet f Private Water Supply Well and Leaching Facility (If any wells exist --on site or within 200 feet of leaching facility) Feet Edge.of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet i. Furnished by .... ,I /? C �V - /z No. 9 FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, MR A2M I,— , MA. APPLICATION FOP, DISPOSAL SYSTEM C®NSTOCTION PERMIT Application for a Permit to Construct k Repair( ) Upgrade( Abandon( Complete System 0 Individual Components Location 19 7- /y2:c Owner's Name Map/Parcel# IV/Q -75 C j Address ji la p(,tf&� /,►/Z- Lot# Telephone# U 3 3, 5-723 Installer's Name �� o Designer's Name 4 ,.1),9 Address /�'f�s1 ,s �� Address Telephone# Telephone# •�/ 3 Type of Building �� Lot Size Z—• sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) � gpd Calculated design flow 5 d Design flow provided— —gpd Plan: Date Number of sheets 0 Revision Date Title al/z Description of Soil s /�,� , Soil Evaluator Form No. RVA1/C . Name of Soil Evaluator" pate 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 further agrees t not to ace a system in operation until a Certificate of Complianc has been issued by the Board of Health. Signed y�v�' Date �� O f , No. 7 GbI' q COMMONWEALTH Of MA ACHU ETT FEE Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System E The undersigned hereby certify that the Sewage Disposal System;,Constructed ( ,Repaired ( ),Upgraded( ),Abandoned4( ) atQ$ U«XFr/ L+tcK rL�tA/ ASS :iNlr��S C.. has been install ' accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. .+ , dated /� Approved Design Flow (gpd) Installer /,-1 /7'4-i 11 k9<7 l Designer: t L 4, Inspector rrl(' r�t,<-f ' � ?� � /V1'ta -te: ' /�/� 101 The issuance"of this permit shall not be construed as a guarantee that the system will function as designed. No. �` X' ` '" R` FEE /OP e/ e !) COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system v q at /Jn r�/ it/�._�L �� 4�s`a s S as described in the application for Disposal System Construction Permit No. , dated � Provided: Construction shall be completed within three years of the date of this permit.. All oc conditio s must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston;MA Date J Z Z w'"board of Health rx SYsi�f PRDF,' so/� s �sr ,e�s�rL.Ts 3 j M,qx. D/sT. BOX W/, SUMP 6"MAX, 9"M/N, I Z" M/N, INY,4g M�ASUQ-�` /.vv, Fc. 9.9 4= 3�''MAX. Z+Covc-,- or '/r' - Yz" sromc- scN;4O /wc L14c//D L�VGL , H, -00 PVC ScH, �/0 PVC /Nl: _ /N✓, ID"M1Nr 1¢' /NVr /,V _ /0,9} 10.72 4 5 ,t /D.¢7 �� /0,Z-7 /,VV, /D./c 3S New v � ' 3/4 //2 GA G ac-D OF . . o :D c (s) soa G. LEA cH cl/AM6i&t� slow QT, A�B SST /VD. 688�f $A CrP1l D $o°ooa t� c= I= � � °660 J,, 2 �F. .DeIP7H 2¢" EL. 7,5' a STo�tE qra� or !ao. 0.+3 hi97P: 3-2¢- 88 . •.. _ A//Ti 465s: .T. dUrVOVAVG USE /5-00 G, PAKAST SEPTIG T•M/K WlTN 4B,r TEST ,BY= rP S[/LL✓1/.9N /NLE TIOIJTLET TFES PC) 310 CMR 15,22,7 _.__.....� )2 /D -_--_..___._.. _,.........�_. s' LOT CoNFo�tMANCE 1NITH ASTM C-1227-93 SH9�G Me 41m 69MiVo h/A74Gle AT EL. -f-o,S 56 DISAIlYCL V/,l FMBosSED SEAL. E[-, .: Z.9 G6" S AD AND TSh/ 89 ZoNE 6 �?c/,_%' G/�O[//VQ 14/�TEFj' C / 4 DS. G.W. A.D.T G"tINA V,47,5.0 EL. 2,.9 ��. 2.9 CL..955 GYVE 7EX7IJX 4Z- Sd/LS -__..._._. OBSVd. 6.W EL. •S - "WASH 12d,i Z L I 1., • , 2 /1''' . E !Get/ I - r-- ••, I2 /D v� /01- 4,A VIC-W OF `q, O� • �" 2 / r / . • T ,4// - EY✓AG 'Y.5TTEiW L /GN G41.C4114770/`l.5 N bg5/6/V b,41LY .440,k> A'7- //O GPD �E.t ��D.QOd✓►J sPTK ,' T�N � �' TrH'/ -' BD/i'/�'i! 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