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0035 BLACKBIRD ROAD - Health
35 Blackbird Road Marstons Mills - -- A= 151 --008 - 017 - :_ No. i 0 / Fee 7 r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:C Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftprication for Misposal *pstem Construction permit Application for a Permit to Construct i; ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Locat'on Addr ss o of N n Owner's N Address and Tel. S���cc�c is`�. s h-(i ll �,a o'em n 30 �c6 k ,/ Ro�� Assessor's Map/Parcel —s-00•41Q,Q staller's N q,Address,JnTTel.No. ! r Designer's Name,Address,and Tel.No. f frnai 1.V 100 3Y)c - .O. kc4 d-J) 6X_ -771 ate' Type of Building: Dwelling No.of Bedrooms k Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildirg No.of Persons Showers( ) Cafeteria( ) Other Fixtures All /� Design Flow(min.required) A k gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 10Cf- ;�jdn�[ O a C3P. wi �Q.S 'in <®3P�.i''1.�, Date last inspected: Agreement: The undersigned agrees to ensure the construction and main e of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmenta ode not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Dated Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 24&T?,! 6 ( Date Issued Z �[/V�, 72 i< J No .,, `' Fee THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE, MASSACHUSETTS Yes 4plitation for Disposal 6pstem Construction Permit ; Application for Permit to Construct( ) Repair(N�pgrade( ) Abandon( ) ❑Complete System . ❑Individual Components Location Address o Lot No.. Owner's N e,Address and Tel jl( C� r11.� r►a. 'r�m �' 3�ifGGk�l �Urc.�, un Assessor's Map/Parcel � ^�11 e j azisi y-i6 46i,or 5V-4,Q6.0 90 Installer's Name,Address,and Tel.No. L3f 'gym Designer's Name,Address,and Tel.No. c3mi ru c-Co ) sane P0.6x kq 1WBl''. i�SM,Plfa ,,�`e.771,4sqq Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) N�� gpd Design flow provided /V//+ gpd 1 r r 1 Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. r Description of Soil Nature of Repairs or Alterations(A+fnswer when applicable) +,0()EQe� r J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore descr_ibed'on-site sewage disposal system in - accordance with the provisions of Title 5 of the Environmental,Code Vd not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by \. ! Date /7.?/ Z-/ Application Disapproved by _ Date r for the following reasons Permit No. C. 6 - Date Issued Z Z Z ----------------- -' -- ------------------- ---------------------------- -THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance a THIS IS TO CERTIFY that the On-site Sewag`e�,Disposal system Constructed( ) Repaired( V) Upgraded( ) Abandoned( )by at C 11;%'r^ ()(j�'`. ;t t � has been conkptsicted in accordance with the provisions of Title 5 and the for _ �Disposal System Construction Permit NO.-I �,(.�t c��ated / e� Installer !9/ �f d�1 brr1 Designer / �i`T4 r Al �' !"F 00 JV r` #bedrooms A- Approved design flow _jA7 gpd The issuance o this permit shall not be construed as a guarantee that the system�41 fu� designed. N e on as dtesigne . Date / 1 Inspector ft, i -OS 7 -_-------•---------.--,-.-----.----.__.-__.__.__._________._.__.__-._:__._._._....___.-_•_.__,_.__,_.._, Fee _.__..-75--_-.---__,._-_-_- THE COMMONWEALTH OF MASSACHUSETTS p PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS D A Disposal �6pstem Construction Permit t Permission is hereby granted to Construct( ) Repair _(/✓) Upgrade( ) Abandon( ) System located at s� 91':q�1C1 Y W !,}'9M and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local proyis-ons or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by .�� a y '♦ r Town of Barnstable �`►� Inspectional Services Department Public Health Division y atnss. g •439• �Q+ f 639 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 8098 February 23, 2021 COLEMAN, GLORIA T TR 35 BLACKBIRD ROAD MARSTONS MILLS, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 35 Blackbird Road, Marstons Mills, MA was inspected on 02/03/2021 by Michael T Bisienere, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: e The distribution box is rotted and needs to be replaced and the outlet tee needs to be replaced. e Per Board of Health policy, it is unknown if the H-20 component is under the driveway. See attached policy. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER � R OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\35 Blackbird Road Marstons Mills.doc THE 1p� Town of Barnstable Barnstable i Y NAB�' Board of Health j a°'°'ca j i639♦ `� � � D Argo A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 FAX: 508-790-6304 October 9,2012 Revised November 20,2013 Public and Environmental Health Program Policies,Procedures,and Guidelines H-10 Components Discovered•Beneath.Parking Areas and Driveways During Septic System Inspections Conducted Under 310 CMR I5.301,State Environmental:Code,Title 5 No.2012-005 When a DEP certified inspector discovers an H-10 septic system component located beneath a parking area or driveway during a septic system inspection, conducted under 310 CMR 15.301 State Environmental Code Title 5,the system shall be deemed as a "conditional pass." The system owner will then be ordered, by the Board of Health,to correct this problem within two(2) years and will be provided several options to rectify the issue, including by: a.) replacing the septic system component with a new component relocated into another area of land which is not beneath any parking area or driveway, and properly abandoning the discovered H-10 component; or by b.) replacing the septic system component with an H-20 component beneath the parking area or driveway,and properly abandoning the discovered H-10 component, (or in the case of leaching pit, replacing the top of the leaching pit with an H-20 slab top); or by c.) relocating the parking area or driveway in such a way that no vehicle will have access or the ability to drive over the existing H-10 septic system component. If it is unknown whether or not a particular system component which is located beneath a parking area or driveway, is H-1�0 or H-20 (for example: a leaching pit is located beneath a paved driveway without an accessible steel cover to grade and there are no records on file indicating whether the system component is H-10 or H-20), the system shall also be deemed as a "conditional pass". In this case,the seller must make the potential buyer(s)aware of the "conditional pass" status,the unknown construction of the septic system component(s), and it's safety concerns. Wayne Miller,M.D. Paul Canniff,D.M.D. Junichi Sawayanagi Q:\POLICIES\H 1 OComponentsE;eneathDriveways&ParkingAreasRevised2O13.doc r , Town of Barnstable Im"STAHOB Inspectional Services Department pffD1AA�p Public Health Division 200 Main Street, Hyannis MA 02601 Oftim 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the'SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) 0 ER Repair deadline: I er4l. Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc c� Commonwealth of Massachusetts 009- 014- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name / information is required for every Marstons Mills f MA 02648 02/03/2021 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. Important:When filling out forms A. Inspector Information S(jp ( 51 a.g on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key._ 52 Rivers End Road r� Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 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 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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: ❑ I have nog found any information which indicates that any of the failure criteria described in 310 CNIR 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 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y »� 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. CityrFown 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: This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a precast leaching pit. The discharge baffle has rot and should be replaced with a PVC tee. The H-10 D-Box also has rot and should be replaced. The leaching pit is under a paved driveway. The plans call for an H-20 leaching pit. I viewed the inside of the pit with a camera but I can not confirm it is H-20. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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 '/z 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 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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 cam, Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 443 GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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: 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 c� Commonwealth of Massachusetts -, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 10/28/1987 Plan Date Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"tee" Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(_locate on site plan): Depth below grade: 24"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: H-10 1000 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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.): 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 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. Cityfrown 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.): At the time of the inspection the liquid level was at working level. l5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments —�— 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 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.): At the time of the inspection no visible failure criteria was found. 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.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. Citylrown 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 **As-Built from the installer attached on next page** t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Assessing As-Built Cards https://townofbamstable.us/Departments/Assessing/Property_Valu... '023' 6 . TOWN F BA NSTABLE ., W k iocATlcN k6r<'9„-� � ��, SEWAGE# 8'-f� VILLAGE, ASSESSOR'S MAP&LOT /$I-OCfO a` INSTALLER'S NAME&PHONE NO. K ,k�'. f�\ SEPTIC TANK CAPACITY /(70 p LEACHIKG FACILITYjtype) p; (size) 1000 NO.OF BEDROOMS �l —PRIVATE WELL O W TE BUILDER OR OWNER L 2.p Q , S O DATE PERMIT ISSUED: �,_ Z 7_ R DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r , o 4o 1 1 of 1 2/3/2021,6:42 PNI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. Citylrown 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: 15 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show four plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blackbird Road Property Address Gloria Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 02/03/2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 z BENCH MARK: sP%'K� t�cLE'•119 u EL6'v. 133.92 IV.G,V.D. TEST,= HOLE, :: RESULT'S 0 ,64a DATE _ a, ..... Rem' 6NLgYL O+CMCN r, OF< ToPawlranrJy .; p WITNESSED BY: -T1Ic7Mi99 ^1Gh'E McG.R BRIfYNI' DUDta'Y�H01.He s1M.�'rRgTN .i- NoL.M G ES { APN �OT?,�N LoT /7 roo ror= Ia 7 17` Mc \.� .. _ o sVtiSOia EL f13. 3V.r3 so E. L174 O _ wwarwr�: ISOOtS7 k 34" qy; 31. ,Halo.snwo f9WD9TR w�FN6S _ .. az....y —•�' a. I 40•• :EL IOS O. �0 u•�Det+C i C LGrHN � MED/VM OPKAPOSCC I uNA :. t i-FAH aY >f l fA E'AIV/YJ .: _ f I I0.8" fw JYgVE'L G6loD.0 DNd•.iL/nlG I SflND � Z`LEFIN s.DNA t; � ��� 'wAlL � 'L 07^1 G �•F ,SL IOJ.O l4q" " L+R iQ0.0 '? z8 eQ NO 'Cn Z. ND w�i r -IL G'NC4 VN 7'�"lC EO rz crun✓, � ., f.01 � MANHOLES AN COVER TO BE:BUILT:TO sr -� EIEV.TOP OF ;WITHIN i2�OF FIINI6NED 'GRADE FOUNDATIONS' _ ! ' �.F�iCM 3� ISH O 0RA E MIN 2:'� 910PE.' S YrT 4"OIA _ 4`DIA, PIPE N2 FIRS 2M .6+Ft NIN.PoTCH T LEV M LAYER 00 MiN.PITON ra �rae . �e��•.PEASTONE �', 7/o.zx .: t'1 pT 1og76 �ozc t' p Sr= caAY �N eovNr. 'INVERT >. �� GALLON INVERT aarrPINYERT '4 �e.k '• - ,1 1. � os. 4�Dif+. PI R.Foa.n rsa 00 IC TAN is !o 83 DIST. o `-- m'� IJDfA. INVERT. INVERT EO% 1.7.9 ��(3,S ct �qq pp 1 /,,T "Jfo Ofia i.v F•fPa w a e! IN -w�a•.. WA SN ED'STONE I �lf-f%:" - PLACE ON J •Y67 0¢ ' ` ALL AROUND D7.n.SroNL_P'tow /O' FIRM BASE �70 9;.' &7 q A� ,:'_. _�l4 I.:. p GARBAGE,- (2�N.1 GOT TOM_74T,ELEY.Jo'. �' A,•.. PLaCgO oy !d M,NINM1LN,1 _ 1 ELEV. lOo.o Lot !g = P.ROFILE. OF BBiS�WArER TAe gaao v '' OG l2�yo,c ViFz-f•'sNo2 oo7� � SANITARY DISFOSAL T M Res e2y� .:Ca PAC-610 mSD I VM .. ' (NOT TO �BCALE j t Arz aH C sayer DESIGN DATA • CONSTRUCTION OF SANITARY DISPOSAL SYSTEM' SHALL CONFORM TO THE MASS. —,� BEDROOMS ENVIRONMENTAL CO.GE TITLE SCDESIGN FLOW3Q QAL:�DpY F7LL c��v„ry E lco relz,eo (REVISED- 7-1-TT) AND T-HE ^.TOWN':OF LEACH RATE MIN. INCH G�Law pJpE ri✓vFn r(E�lov,5� 9y 69f2AJ5T.9 CiLB HEALTH REGULATIONS. REQUIRED LEACHING CAPACITY:330 J O SEPTIC TANK DISTRIBUTION BOX AND 1EACM PROPOSED " �t43 G!s To AIe�OAY zs� 2EPLacD io' 7cL (� ING UNIT TO BE OF 'REINFORCEO CONCRETE l a:,lla us irN ce Fa / cocas MIN. CONCRETE STRENGTH• 300Opal REQUIRED SEPTIC TANK: 1040 L= MIN STEEL STRENGTH • 20.000PS.I. MIN. DESIGN LOADING: H2O PROPOSED /SEPT.`IC TANK: l000Gr4t. ... .' f DRIVEWAYS ,NOT,.TO BE..LOCATED OVER SYSTEM { UNLESS: H20'' DESIGN: LOADING IS USED ' ♦ ALL PIPES AND FITTINGS TO BE WATERTIGHT AND :TO BE OF CAST IRON OR 'APPROVED PVC, ' HEALTH AGENT.APPROVAL DATE SITE PLAN $ HOWING PROPOSED COtdSTRUCTION ZONING DATA LEG:E:ND LOCATION•-CAmeV.S ss, oPEN 's�F�cE ,v !2 ^°^ FOR:: Lam - scat�caWZ n ✓. CaF,rDAfE' �fz�/a4 20NE _ _ _ _ TEST HOLE LOCATION REQUIRED AREA: _ =5<O IO, EXISTING SPOT ELEVATION IT.6 F j RE EREN�iE L� . /•mil s sriowv � 23 8 e90 Hom I REVISIONS z REQUIRED !FRONTAGE.`•_ �)sej 37. EX.:ISTING CONTOUR ---16 4�i *, EELS REQUIRED FRONT SET.BACK'(30) 3.6 ' „ . 'f '✓ fYA�13K 12c. ?G 44, 4.g PROPOSED CONTOUR REQUIRED SIDE SETBACK !S !o'er .% ai" ^' SCALE PR,OP08m:WATE'RI!SERVI:CE W - REQUIRED' REAR SETBACK: P RID POSE 0 GAS SERVICE .—G a it Pe7 P/ y/14107 PROPOSED a TELE :—E9T— CR . SHQRT A1G R , P.E: PROFESSIONAL CIVLL EN0/NEER BUILDING INSPECTOR APPROVAL DATE Iti: OLO ROUTE 132', HYANNI9, MA.' 02801 FILE NO./•.5"42 342-5-f// BHEET 11 OF t HaE e-TN PF/+MF '� 66 a 7- f - a ... ,per -\ Conunonwealth of Massachusetts Executive Office of Elvirolunental Affairs Dept. of Environmental Protection John Grad One winter Street,Boston,Ma. 02108 ` D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI \� f Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A CERTIFICATIONjn 1/ V 35 Btac ird Rd.hlarstons Mills Address of Owner: �✓ Property Address: � Date of Inspection: 7122198 (If different) 'e4hsr 9'9 j Name of Inspector: John Graci Wilbur For9gzF f I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) I Company Name,Address and Telephone Number: 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection is based on criteria defined In Title V _ Conditions Iy Passes code 310 CMR 16.303.My findings are ofhow the system Is performing at the time of the inspection.My inspection does _ Neeiubmit her valuation By the Local Approving Authority not Impyany warrentyor guarantee ofthe longevity ofthe Fall septic system and any of Its components useful life. Inspector's Signature: Date: 7122198 The System Inspector shall a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoMpliance(attached'indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Bcard of Health. (revised GM7)97) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 Black Bird Rd.Marstons Mills Owner: Wilbur Date of Inspection:71221[98 — Sewage backup or.breakout.or high.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 Black Bird Rd.Marstons Mills Owner: Wilbur Date of Inspection:7/22198 D] SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 35 Black Bird Rd.Marstons Mills Owner: Wilbur Date of Inspection:7122198 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _x_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with NIA. x The facility or dwelling was inspected for signs of sewage back-Lip. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System,have been located on the.site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3;i(b)) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 35 Black Bird Rd.Marstons Mills Owner: Wilbur Date of Inspection:7122J93 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd). nia Sump Pump(yes or no): No Last date of occupancy: nia COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:o gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no)-No Water meter readings,if available: nia Last date of occupancy: nia OTHER:(Describe) rva Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1000 gallons Reason for pumping: Maintenance TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records; if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 1987 Sewage odors detected when arriving at the site: (yes or no) No (revised MUST) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Black Bird Rd.Marstons Mills Owner: Wilbur Date of inspection:7r22J98 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age nla . Is age ccnfirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'e••h5.7••w4•10" Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 15" ' How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic lank and all components are structurally sound.'.Recommend pumping system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: rda Material of construction: concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle:rda Date of last pumpingn Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) We BUILDING SEWER: (Locate on site plan) Depth below grade: 2-6" Material of construction:_cast iron r_40 PVC_other(explain) Distance from private water supply well or suction line?own Diameter: nla q.,mments: (conditions of joints, venting,evidence of leakage, etc.) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Black Bird Rd.Marstons Mills Owner: Wilbur Date of Inspection:7122199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n!a Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: We Capacity: nla gallons Design flow: rda gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) No DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) nla PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Y.: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n!a (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Black Bird Rd.Marstons Mills Owner: Wilbur Date of Inspection:7122/98 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: nla Type: leaching pits, number: 6'x4'leachpit leaching chambers, number:rya leaching galleries, ni imber: rya leaching trenches, number,length: rya leaching fields,number, dimensions:nla overflow cesspool, number:nta Alternate system: nra Name of Technology:_nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit was structurally sound and functioning properly.The leach pit had 2'of water In It at the time of the Inspection. CESSPOOLS:_ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: rya Depth of solids layer: rva Depth of scum layer: rva Dimensions of cesspool: rya Materials of construction: rya Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) nla Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nra PRIVY:_ (locate on site plan) Materials of construction: r0a Dimensions: n/a Depth of solids: rya Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla (revised 04127)97) , • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 35 Black Bird Rd.Marstons Mills Wilbur 7122198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) �A �6 G PIC i � Cl co �1 � Q Page ! of 10 (revlaed 04117/97) „ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 35 Black Bird Rd.Marslans Mills Wilbur 7122198 Depth of groundwater ,?` Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers _x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts Fag* 10 of 19 (revised 04BT19T) l Commonwealth of Massachusetts AL Executive Office of Environmental Affairs . John Grad.D.E.P. Title V Septic Inspector- ® p art me Wiflii- ag a P.O. Box-21-19 - Invelr jf�1t umenNou 1?@QS(gQQQ(M Teaticket, MA 02536 VA tam F.weld (508) 564-6813 Gammor Tardy Co:e B�cntw .EOEA Dovid S.Struhi Commissioner SUBSURFACE SEWAGE DIS OSALRAYSTEM INSPECTION FORM'; CERTIFICATION ` — 'r 0 Property Address: 3�J �kGC. .tQ,( l �C� �' ���1►ddress-of Owner: _ 9��' �• ! I ail Date of Inspection: c,�j�n�L (if different) '¢ Ik 4e f Name of Inspector: - Company Name, Address and Telephone Number: -----�' CERTIFICATION STATEMENT I certify- that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance,of on-site sewage disposal systems. The system: t/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: A's Date:. r 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be seni to me system owner and copies sea; to the buffer, if applicable and the appro.ing all*L it). INSPECTION SUMMARY: Checl, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Boars of Health. (revised 8/15/95) 1 Ono Whnor Street o Boston,Massachusetts 02108 a FAX(617)356-1049 a Telephono(617)292-WW q0 Printed on Recyded Paper SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION (continued) Property Address:.. - - Owner:_ �\^ - Date of Inspection:. B] SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout"or high static water level observed-in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s).are replaced - _obstruction is removed distribution box.-is levelled or replaced The system required pumping more than four times_a year due-to broken or obstructed pipe(s). The system will pass inspection if(with approval of-the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ine >�stem nd> a >euu( tang anu Sun db5orption sybitni and 6 Vrith*li-i ivv fcci lc, a su'acc sUpp!-, G. zT*.' ;zzr, iG d surface water supply. The s\s!P^- ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water- supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. DI SYSTEM FAILS: , I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis, for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A _ - - _- - CERTIFICATION (continued) Property Address: - Owner: _ Date of Inspection: �� D] SYSTEM FAILS (continued): 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a public water supply well, The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- - - - - .- _ PART B — CHECKLIST - Property - Owner'.` �CCr ,`o Date of Inspectio` Check if the following have been done: _L-FG`mping information was requested of the owner, occupant, and Board-of Health. _L,wi5le of the-system components have been pumped for at least two weeks and the system has been receiving normal-flow rates- during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. `jYr built plans have been obtained and examined. Note if they are not available with N/A. t'frfacility or dwelling was inspected for signs of sewage back-up. L K system does not receive non-sanitary or industrial waste flow {T site was inspected for signs of breakout. _l_,lt system components, excluding the Soil Absorption System, have been located on the site. �- fe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _�Jke size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b\ non-intrusive methods. if diffPrP.,, frnm ov,ne,' were orovided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM-IN FORMATION Property Address: 35 tGL�l _ - _ Owne �� _ - -- Date of InspectiL�AJ��� - FLOW CONDITIONS RESIDENTIAL- Design flow: 32L ga1^IIoons _a Number of bedrooms: _ Number of current residents:G - Garbage grinder (yes or no):�Y� Laundry connected to-system ( es or no):=ae� Seasonal use (yes or no): ��LQCIc�� Water meter readings, if available:- Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupanc}: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)ac—\ If yes, volume pumped gallon, Reason for pumping: TYPE OF 55TEM eptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at thie site: (yes or no) (revised 8/15/95) 5 I -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ -_ . SYSTEM INFORMATION (continued) Property Owner. i Ccc`(1J\C,(1 _Date of Inspection: — -_ SEPTIC TANK: (locate on site plan) _ Depth below grade: Material of construction: G-Co"ncrete _metal _FRP _other(explain) Dimensions: LFSd"il 43*-1tt 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 bottcm of outlet tee or baffle: Comments: ' (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence leakage, etc.) t q c•rS GREASE TRAPa ) t (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum tnickfie». Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt <rt,— to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/!5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - PART C SYSTEM INFORMATION (continued) - - Property Address: Owner�'c Date of Insp ion: -- -- - TIGHT OR HOLDING TANK:_n\(� - (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP _other(explain) - - Dimensions: Capacity: - QalIons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:—V--' (locate on site plan) Depth of liquid level above outlet invert: \- �� `x�`�� ��r\ ( , rx "C�� y Comments: (note ii levei and distributtun a t•yuei, c' i]c Cc of so;ld� ca:,)u'.er, e�:dence of leakage into or out of box, etc.) PUMP CHAMBER:-L\11� (locate on site plan) Pumps in working order(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 �r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM -PART-C- SYSTEM INFORMATION (continued) - Property Address:.35 Z\C,( i' Owner: -�cSr(\ �G �_- Date of Inspection:,— SOIL ABSORPTION SYSTEM (SAS): L/ - (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: _ leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) sri—s CESSPOOLS: "A (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions or cesspool: materials of construction: indication or groun&.atc- inflow (cesspool must be pumped as part of inspection) 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.) (revised 8/15/95) 8 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ SEWAGE PART-C - pp SYSTEM INFORMATION (continued) Property Address:- 3�j J�C'cccbtd< (�\\ -- Owner �S`�llc�C> -- -Date of Inspect�o SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks — _ locate all wells-within 100' - GrGt f Pr C. DEPTH TO GROUNDWATER Depth to groundwater:__a feet method of determination or approximation: J (revised 8/15/95) 9 TOWN OF BARNSTABLE LOCATION t�, �`� R �� SEWAGE # SG g�fi 2 VILLAGE ASSESSOR'S MAP & LOT I S/ -tCO V0 INSTALLER'S NAME & PHONE NO. '(, , C -: -?�;Z \ SEPTIC TANK CAPACITY 0 O LEACHING FACILITY:(type) (size) 600 NO. OF BEDROOMS �7 PRIVATE WELL O C WATE BUILDER OR OWNER S 0 w S DATE PERMIT ISSUED: -�� DL 9 — DATE COMPLIANCE ISSUED: :;L _ / — VARIANCE GRANTED: Yes No --'"`� ut 0 Lt t� <� '�. yf 017 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH XV111 rFatilan for Disp agal Works Tonstrnrtuan ramit Application is hereby made r P rmi to C st~ (j�r R�p„air ( ) an Indivi al Sewage Disposal System at: �S^ � C� f'//G , .... ® ._/..1.... ...•-••-•--=• ............ ..---•--•. --....... .. . _ on-A ress t No.SG S V.S T -----1. 1Oc- ... ....__Z-----71 -..---•----------------- ... 1�` ._.Y �-- ..5 O ner Ad ess W -- ---( �.�.�=: ......................^V.--s..---1 '..................©-S._�........ ✓/L c F �'i�I /9� astaller Address Type of Building Size Lot..._�.S�_-.Sq. feet Dwelling—No. of Bedrooms....................... ................Expansion Attic L-4 Garbage Grind��-E—� ayp g �.._. �^'VNo. of persons......46.................. Showers.,(---)-- Cafeteria-(-�Other—T e of Buildii.� ...____. Otherfixtures --------------------------------------------------------------------------------------------------------------------------••--•--------------------- W Design Flow............................gallons per person per day. Total daily flow............ .............gallons. Septic Tank—Liquid capacity ®Ck .allons Length_ .._(✓._._ Widthj.../-d_. Diameter________________ Depth.., ....&. W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... Diameter.....I. `.___ Depth below inlet..Ae p __....._.._. Total leaching area..Z-.�-..__sq. ft. Z Other Distribution box ('1-K Dosing to a Percolation Test Results Performed by._..... ..Q,.................... Date_ r ✓ __ _ �a_.... / Z ¢- ,..a Test Pit No. 1....—._Z..minutes per inch Depth of Test Pit.................... Depth to ground water_.)_:Z!�_.___...._.__. Gi, Test Pit No. 2__.'e-.2--_minutes per inch Depth of Test Pit----J..�..... Depth to ground water----- Z-_.�'__. R.' .i............. �r -•----------------•••••-••- ------- --- �`�a 3 O Description of Soil 2 �r -- --.°�--•--•.. wrY ..... Z- . x V ....._..-•••••---••--•-•-•......•-••-•----��-�......... ..*....c _ %41 '-': r -......•.cR ... crQci W VNature of Repairs rations er when applicable............................................................................................... -------•-----•-----••---•--•-•••----•-• ....... ............................................-------•--•-----•---...-------•-----•--•-•-•-•--•--•••--••.._..---•--•-•---... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITiU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of healt Si ned. ; ® / � r ..............Approved -....._.---...f----------- Date Application Disapproved for the following reasons:---------•-•--••------------•-------------------•-••--------................................................. ---••-•-•........._..••••••-•------•-••----•-•.---•--•---•--•------•--••--•----•-------•---••-•-•-••....•-----•••--••-•-------------------•--•---•-------.............................................. Date Permit No.--------- LI°�. ---- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 7-0 ............. .......................OF................:... .............................................................. Anpliration for Disposal Works Tonstrur#ion Prratit Application is hereby made for a Permit to Construct (t. ) or Repair ( ) an Individual Sewage Disposal System at: .....---........_...............••-----------.....-•--------------------.............. .....------•-•--••-•-------- ----••-•-- ----- ................. Loe n-Address or Lot No. - 4 � -�........................�...�......�_:5..:..::....-_.._..-/a--�-- --�----...........-. ..''..........-- --- ' y'' ✓ ✓�s _ Owner _ / 4 .............................. ................. __.............. ._..._....___._________.. ...._.__..._............_....____.-•.._. ___._.................__. Installer Address d Type of Building Size Lot.1_S____ ....7..Q.Sq. feet Dwelling—No. of Bedrooms..._ ______`..............................Expansion Attic ( ) Garbage Grinder-(—) Other—Type of Building (----- `.2_. '22 No, of persons....-!..................... Showers-(—)-- Cafeteria.( ) P-4 Other fixtures ----....._.•.•• -••--•-•----. --- WDesign Flow..._......._ .................gallons per person per day. Total daily flow-------.._-_�-�_�-- ©_............gallons. WSeptic Tank—Liquid"capaci_y'.a�Ugallons Length:©._..h -_- Width!.....!_�___. Diameter................ Depth._ ...........' W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area................---sq. ft. 3 Seepage Pit No.___-!_-------------- Diameter.._..__._..._..... Depth below inlet 3___ =....... Total leaching area...�.z- -sq. ft. z Other Distribution box (L-')' Dosing tank-(---)- a Percolation Test Results Performed by---- - --`--/ ?-- :-•-- �.?-r�nr 2. J� Dates-�. �Zf.-•(7...... W Test Pit No. I..`:_..7.._._.ninutes per inch Depth of Test Pit.../..Z-_......._ Depth to ground water. ...... ......... 44 Test Pit No. 2._"!�... --___minutes per inch Depth of Test Pit...L?........... Depth to ground water----1_. ...... W ._................................................................................................................................. .........r._ r S D Description of Soil.........2 �}_...:. t'- J V_ --b% �---," ` -`7 J J �'..r-.. _ a , -' ---- -------------------------------------------------•-•-•......--•-•-•--••••••. ----••......-•••••••. W ......................................................... -•-------••••••-•••---•-•-••-••--•-••----•---•---•••••--------•-----••---••-••......-•-•-••.................................................. V Nature of Repa> s Iteration swer when applicable. Agreement: �/"^' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 5 of the State Sanitary Code— The undersigned fur e&arees not to place the system in operation until a Certificate o Compliance has been isstlby t e oa d of hea Si ed r �------••--------------------------------------•-................ = f�� .! (/ Application Approved BY................................... -------•- - ....................................... Date Application Disapproved for the following reasons:--------•-----•---------------------------•-------••------------------- ---------------------------------------- --.......•-•••-••••-••••-•---•.-••-•--•--•••-•••••---••-•-•••-•-•--•••••-•------••-•.......•-•------••••-•-............................................................................................ Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... rJ..}/t/!1,!.....OF....� '' .. ..!.; ...... : ............... Trrtifiratr of Toutpliaurr TW,JSj- 01_fE,1'jV, Th?�2thtjIgd�J •idualiSewage D e, �tr. ct A �W-`or Repaired ( ) b ...............................................-----------......_...-----•---- Installer --- ------ - ..............................................has been installed in accordance with the provisions s of Tl� of Jq S ate Sanitary s� s G� in the application for Disposal Works Construction Permit No......................` '......_....... dated------------------- ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. ...- -AK..........--•------------------ Inspector................ l�•---............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L- 2..........7..~ ZV� 0F....� �? .n / _s , {�-3. 1 No.... ...---__ FEE........................ Disposal� Works T ust ttrtion rrrmit Permission is hereby granted.......... !_..f__r__.r;' � /'✓S -% <=� e' i°-•=�✓�d 4� .............................................. to Construct ( /) or Repair ( ) an Individual Sewage Disposal System at No.._/moo- .-'•,�• '� I--' ,r J/ %?.._....J.: Street as shown on the application for Disposal Works Construction Permit No.__t,_........_.' .__ Dated-_____-__. Board of Health DATE / •------------•�....Q,� FORM 1255 A. M. SULKIN, INC., BOSTON BENCH MARK : SPIKE U �- L� � . ► 33. � � N.�. � D. TEST HOLE RESULTS P ,5-Co43 0 8 DATE : WITNESSED BY ?"HC2, m of;cA�/ T aPa C"R,9PHY FRorv� t^NLAtzG � /v1L�'NT o� BO' S C ALE' � Y H01- � 5 �` M �G,1?,9TH, ;✓ rlC�LMEs /Ylo�n!?RTH CD. O C7. • - ` p 7-// E L 113. 0 p 7"/-�, T o � 4v 4 s t�13-So/.c,. � 4 , �Ll/ov 3 �.r � >' � $Qa ± ST 3� hr�Elr3. S�anep � .r C q2 �0.• �-G / o�,� t!e on /o? O VMDAT/4i — 1 C G EAn/ N►�,a�vm Sd ! . Zr oPJzoL J�osE-a R-od)V c. �4/O3,0 - Y aw •t� �/n/c, I14 D C� r SF�N F� O ` Gi•A2 � �, © 144 n G• 1 ©/.4 1 QQ EL rOO,q '' �\ 22• !" • r ! 8 A!© G7 ,�Z o (J N ,7 W',1c)T'f-�"fC. E'^/c t7 V n1 T.r, Ic TZ ETA/i✓, - �� I �" `� 6-L J JrQ.©O �R« l�Ra I ELEV. TOP OF MANHOLES AND COVER . TO BE BUILT TO WITHIN 12�� OF FINISHED GRADE st>Ti �� :.: FOUNDATION o o - � FIN 2( SHED M /o $i1 8Z 1 .,', GRADE IN, LOPE 4 DIA. PIPE H Z0orFIRS u 'PIPE "'", ,H2C> MIN.PITCH 2•LEVE • MI N. 2 LAYER OF FT. EE ` T o l �?, -\. —gr• , - r • . I +I PEASTONE • MIN. PITCH �I••Miw. �8 �2 a 9 :': I/4 F T. OpC�^'`z1V 109,7 5 107.47 •� '~ GALLON INVERT 6"scP INVERT N IQ• • INVERT � • �5 .- . ..� . .rF CLAY E covNT, �• 0,o /o7. 83 ••® A, �• '•, I .I D A. 4 D I S T, o Q m cx ! SEPTIC TAN ;< •, m �4 2 Di�9. PER l-aR.�rFa • ' 7.`' . • INVERT = - - INVERT BOX / �• 3.svZ D•'•• WASHED STONE D I2 A,nr P J P F v-/ 3 M I N V E R T • ©© w • :-• - �61 0 �, t � ti ALL AROUND � /•( -//z PLACE O N ,�. _ •. ® cv� � m 57 7 BOTTOM AT E E FIRM BASE --- � --- �t---$ °' J gt;• r V, o L ig; w, F..�0. - NO,GARBAGE ( 2 0' MI N.) 3 9 50 GRINDER ELEV. • f'L� c� U o/v_ �7 Nc lNl n�vM PROFILE , O F GROUND WATER TABLE, d3�'.�.o✓�' i Lo Ili a - or / 2 of v 2 SAN1 �'A.RY DISPOSAL SYSTEM , MEDIc tV7 ( NOT TO SCALE sA<va DESIGN DATA Z • CONSTRUCTION OF SANITARY DISPOSAL 3 BEDROOMS '��• - / SYSTEM ' SHALL CONFORM TO . THE MASS. DESIGN FLOW � � GAL.�DAY ENVIRONMENTAL CODE TITLE 3 L LEACH RATE MINJINCH. ADZ C4-, r'� �Ncov,�rr.�� E� (REVISED . 7— I-77) AND T-HE TOWN OF, REQUIRED LEACHING CAPACITY : 330 . "' H E A'L T H R E G U L A T 10 N S. J • SEPTIC TANK, DISTRIBUTION BOX AND LEACH— PROPOSED 43 GAL/DAY. ING UNIT TO BE OF REINFORCED CONCRETE : MIN. CONCRETE STRENGTH 3000PS,1. REQUIRED SEPTIC TANK : '.�e fx'°`N CLE'A �i ` Cv�trs MIN. STEEL STRENGTH * ' 209000 P. S. I. MIN. DESIGN LOADING : PROPOSED SEPTIC TANK Joao �► 3L• • DRIVEWAYS NOT TO BE LOCATED OVER SYSTEM UNLESS H2O DESIGN LOADING . IS USED • ALL PIPES AND FITTINGS TO iBE WATERTIGHT AND TO BE OF CAST IRON OR 'APPROVED P.V.C. HEALTH AGENT APPROVAL DATE SITE PLAN SHOWING PROPOSED CONSTRUCTION ZONING DATA LEG E N D L.O C A T 10 N -- 13A�17Z /\/ :'' 23 L 5 T'ca•y,-5 /,gsz. sue - �✓ i - N-6 F 0 R 2•7• "" « s 0 .s ,� '°t � DATE .: 2/2 9 f ZONE — TEST HOLE LOCATION \a " of rAss��� . -"` o ,nr 3 r p� CRAIG ��'z REFERENCE _ � : � ` ' REVISIONS • 21167 REQUIRED AREA : eg0 EXISTIN-G SPOT ELEVATION 17.6 SHORT ."a a _- T3 �/?-A/, R E I ©r D, io 28 8 REQUIRED FRONTAGE _(1Q� 37,.5� EXISTING CONTOUR 16 � I s� 1� .✓ '1 �/ 13K 2G -* 46 REQUIRED FRONT SETBACK (, PROPOSED CONTOUR r �rALE� SCALE • / -: 30 REQUIRED SIDE SETBACK PROPOSED WATER SERVICE W•-- REQUIRED . REAR SETBACK : I.S) PROPOSED GAS SERVICE G Per ;3,oc.► J PROPOSED ELEC. Sri TELE E & T CAIG R . SHORT .' P. E . PROFESSIONAL CIVIL EN G I N E E R BUILDING INSPECTOR APPROVAL DAT E 131 OLD ROUTE 132 , HYANN 189 -MA, 02601 FILE NO. (r�LE- �' �C•/7 3 (e2- 9 �fII SHEET OF .�