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HomeMy WebLinkAbout0191 BLACKTHORN ROAD - Health 191 BLACKTCJOW 1 ROAD MARSTONS MILLS - - A = 046 - 025 No. i'U� '-O s l Fee l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s 01pplieation for Misposal §�pstent Construction i3ermit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System [;4/ndividual Components Location Address or Lot No. 191 OL 4 -v"Ofv,l Fb• M M Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel 014 G 025 ttCA-,J-,A ( FttNtk IE*LTY TRUST Installer's,leiqri1e,Address,arld Tel.No. �q ga-r 13.E Co. Designer's Name,Address,and Tel.No. 363 IN K} Tq+r" S. yarc"'O-hl SoO - '-tl1 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) 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){Etl 6 f ) b133 410 19o)k W. `m U r (0" bt I oIJ 9 Ra De Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth. Signed Date 3 ' � 2 1 Application Approved by 12 jr X Date ? .2 -1 Application Disapproved by Date for the following reasons Permit No. 2_0 1 Of Date Issued „'„'i.'c„•.r'Me•s.....:'..r,,,ry,.rrrrc:`s.r,: �.... +.ram.,' •........ ... ... 's'..'ir�.v w. ,. .n,,. r. .. ... •.r _., n-. .. r..,,. ,.,- � .. ,- .��. y, ..,.�,,,,,.,,.. . No. i 6 s(J a Fee 4 w THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer: / PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippIitation for,Misposar *pstrm' Construction Permit ,,ti Application:for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System Vividual Components z 11I 8"h(v rNon^l Kb- MM w Location Address�'or Lot No. Owner's Name,Address,and Tel.No. Assessor's MapTarcel 01-I G O 2 S ti ���t 0 FIA 1�t tl, RiE,*LT Y TI:,JST Installer's NamelAddress,and Tel.No. R;t.,;-r G.o x(o, Designer's' ame,Address,and Tel.No. 3C S Sao - `1114 Bull Type of Building Dwelling No.of Bedrooms' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Pelons Showers( ) Cafeteria( ) r Other Fixtures Design Flow(min.required) 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) Th.t 1 t, , ��� N10 Box t� 1 nscr bz cw "DP . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ` accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of i Compliance has been issued by this Board of ealth. 3 Signed Date Application Approved by r IV Date 7,,2 -.2 Application Disapproved by. V Date for the following reasons Permit No.{{1 C, r Q Date Issued ? - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ° Certificate of Qtompfiance POP THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by. at ►6 i gj,_j'ft kW_^ ,lr_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.201J/�0 p dated F-.2-.7/ Installer Designer ;W,, #bedrooms Approved design flow n A/l , gpd f The issuance,of this permit shall not be construed as a guarantee that the system willrfu—nctvon as designed /f Date ;, ') I Inspector _ ��,. L 1 ;U V ET Fee 7� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal &pstem Construction 'ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon System located at t ) 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 provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. fn Date /- b ( Approved by {�+! '7�( F/ G c Commonwealth of Massachusetts o y(,o- o as- Commonwealth Title 5 Official Inspection Form fI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... % 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 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'/-(r lsaa-7:�- on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Jim The Inspector Man use the return Company Name key. P.O.Box 784 � Company Address West Yarmouth Ma. 02673 City/Town State Zip Code 508-364-4398 SI 14430 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 N OF'MgS,S,�4 ;U •• 2. ❑ Conditionally Passes Doti O, G� MICHAEL '.N 3. ❑ Needs Further Evaluation by the Local Approving Authority S o; SEARS *? No.SI14430 4. ❑ Fails IN 3-18-21 Inspector's S)Pdu 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 C Commonwealth of Massachusetts Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Black thorn Rd. u— Property Address Brewster Baptist Church Owner Owner's Name information is Marstons Mills Ma. 02648 3-18-21 required for every 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 worki-Ig order 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or reipaired. 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 —1ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 cam, Commonwealth of Massachusetts �. 1p Title 5 Official Inspection Form I4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 191 Black thorn Rd. v Property Address Brewster Baptist Church Owner Owner's Name information is Marstons Mills Ma. 02648 3-18-21 required for every 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 FIND (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 FIND (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 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form +- I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Forums Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 page. CitylTown 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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 page. CityTTown 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form ~ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ !% 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is Marstons Mills Ma. 02648 3-18-21 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes;, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2019- 12000 gal2020- 6000 gal Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts +� ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments u— 191 Black thorn Rd. Property Address Brewster Baptist Churcn Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 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 y Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA 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 �d Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Black thorn Rd. u� Property Address Brewster Baptist Church Owner Owner's Name information is Ma. 02648 3-18-21 required for every Marstons Mills page. City(rown 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: 8-9-77 #77-600 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 C Commonwealth of Massachusetts �- Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Black thorn Rd. u Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 101, Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 gal Dimensions: 1" Sludge depth: Distance from top of sludge-to bottom of outlet tee or baffle 29" 0 Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with baffle in and out in place both covers 10" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 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 c Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is Marstons Mills Ma. 02648 3-18-21 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):, D Box is 16x21 with 1 outlet pipe box is 22" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .; 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 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: 1 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Foam w <iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... !% 191 Black thorn Rd. u- Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 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.): SAS is a 1000 gal pit, cover at 28" below grade SAS is clean and dry with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 191 Black thorn Rd. u� Property Address Brewster Baptist Church Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3-18-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Black thorn Rd. -- Property Address Brewster Baptist Church Owner Owner's Name information is Ma 02648 3-18-21 Marstons Mills . required for every -- — —" - 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 14 O gar �J N� S�o5 3 ��•�v�,`��N OF l Mqs Z# MICHAEL '••N SEARS No.SI14430 A' �' a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 191 Black thorn Rd. Property Address Brewster Baptist Church Owner Owner's Name information is Marstons Mills Ma. 02648 3-18-21 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 124' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8-9-77 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: No ground water per plan 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 `'=Orin < Subsurface Sewage Disposal System Form Not for Voluntary Assessments 191 Black thorn Rd. u Property Address Brewster Baptist Church Owner Owner's Name information is Ma. 02648 3-18-21 required for every Marstons Mills 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 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 Gale s' m o4 SASll� 3' L %Y- Na `joo• �� t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 - LO�CATION /g/ SEWAGE PERMIT NO. VILLAGE i- L S INSTALLER'S NAME & ADDRESS B U I'L D E R OR OWNER DATE PERPA1T ISSUED DATE COIifiPLIANCE ISSUED ,ryas ' 4;y R EA& o 7— No G------- r ° Fus...l.,>_ �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. TO.N...........OF..........BARNSTABLE Appliration for Uhipaiial i9orkg Tonstrnr#inn ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Blackthorn Road-,—Marstons Mills 448 ................_--......_....................................•-•----••--•----•---•--••. •-----------..........--•------------•-----------------------•--............-••-_.... Location-Address or Lot No. ,1.••-••.c .!�_�._.... ._...:1�° y ` ---•-j `,[ ►��•►�-l-S• ............. a.... Owner Address a 13 - -�--r/.............•-•-••••---•--•.....-•-••-•-•• -••---......_._..__........ _H...A_f'_..----...................................................... Installer Address d Type of Building Size Lot... ........Sq. feet U Dwelling—No. of Bedrooms................... ........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria p-' Other fixtures ................................. 110 gallons per bdr per day. Total daily flow.....................330_-_ Ions. W Design Flow................... g P P Y Y l� WSeptic Tank—Liquid capacityl.O.:O.Q..gallons Length.$.-'•-6". Width_4'.-.1.Q."Diameter..._......... Depth5_'.:n4"._ x Disposal Trench—No. .................... Width.................... Total Length...._............... Total leaching area....................sq. ft. Seepage Pit No....... Diameter..._1Q..__..... Depth below inlet...6............. Total leaching area....3-4_Q......sq. ft. Z Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed byCage...Cod._Burv-ell._QonsultamtsDate.............8./.�,17.7_.......... ,aaa Test Pit No. 1....2---------minutes per inch Depth of Test Pit....12.......... Depth to ground water.....none....,. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wat ....... --•-•-•.•••-- . ..._ �S"_OF. x Description of Soil............,�.e----at aChad..pla I-•--••-----------------•---------------------------------------.....--- --- �y FFOBERT a V .........-••••••-••..............•--•--.....----•-••__.._____-•••-•---•---•-•••••.............••--•••--•-•--••---•••-•--.._.....•-•••••--•------•--•••-••......._... og------------F-----------tA W •---•••---••......------•------------------------------------------------------------------•--...••-----••-•---•-•----------------•••........................-_-••• DAYL-OR......•v► UNature of Repairs or Alterations—Answer when applicable------------------------------------------------- ___ rp_N4.23741. __.. ••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a itli the provisions of iI',T 5 of the State Sanitary Code— The undersigned further agrees not to place the system is operation until a Certificate of Compliance has been . s i, by the board of health. Signed......V.....- - --------------•-----•••----•-••------------•-•-----------------•• -------------Date ApplicationApproved By.................................................................................................. -----------------------•---------------- Date Application Disapproved for the ollowing reasons---------------•------------...-•---...-•---------------------------------------------...._......-•----•----•-•-- --•---••.................•-•-••--••-•-•-----••-•---_•••-----•-----•••---••---••••-••••-•-•-•••--•--•••-•--••--•---•--•---•--------••-- ----•----•--•••••---•---•----•----•-----••......---••----...-•--- °°�"�7._ Permit No --•/(�. 0_----•--------•-------••-•--------•--. Issued........................................... Date ----- Date No................ - Fes$.... �f'~. .. f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN.. ....-.OF...........B.A10T.S.TML Appliration for Biopau al Workii Ton,sirudion "trnti# Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Blackthorn Road,6Marstons Mills 448 Location-Address or Lot No. ���t .;!. o, n i•t�1�vi. ti_:. �....... -o.h?_ ?.-••-• '1 a x f? 1-,�1�A r� Owner Address Installer Address Type of Building Size Lot..-2 219 91•--_--_.Sq. feet U Dwelling—No. of Bedrooms................... ........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria QIOther fixtures ......................................................---------•-- -- W Design Flow_,..........110_______ gallons per a per day. Total daily flow--_-__._...._-._. 330 gallons. WSeptic Tank—' Liquid ca.pacitylQOD_.gallons Length.8.-_---.5._.. Width.4_-.--_10.'Diameter................ Depth.524.... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Piti No...... ............. Diameter....�.0'........ Depth below inlet.... ......._..._.. Total leaching area....l4_Q......sq. ft. Z Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed byCaPe_._CQd.._SUrVey...Co2isultantSDate.............$/__V7_.7.......... a Test Pit No. l----2.........minutes per inch Depth of Test Pit..._.12.......... Depth to ground wat . ....... Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground 41-oF_MgB� _ROBERT �c x Description of Soil-----------See___Attaphad—_p_plan �_----------F----------- •--•----•--••-•••-•--•------------------•--•...-•----••-------•--•-•-----•-----------............--••-•-----•••-------------------•-••..... U v DRYtfjR yr W •-------•----•-----------••-••---•-...-•----•--------------•--......................... up-•237A1,©_ - UNature of Repairs or Alterations—Answer when applicable..__________________________•_-._-_-_-_--. -•----------------------------•-•--•------••-----------------------•------------------•---••------------••----------------------------------••••-•------- Agreement: 7 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a or d nce�wit the provisions of TIT?.,. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,issued by the board of health. Signed..... ~1_ h:_.` '---------- IV Date Application Approved By.....................................--••--------------•---•---••-•--•----•--------------------- ..--•-------•----------•---------------- Date Application Disapproved for the following reasons:................................................................................................................. •--•---•-------------------------------------•--...-------------------------------------.....------------.......--•-----•------------------------------------------------------------------•-•------••-- Date PermitNo -:C?_G ------------------------------------- Issued.......................................... ----------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Off HEALTH ...............1...1�(Ni...........OF........ .....GGfii ................................. Tntifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by .U!- h----------------------------------------•-----•------------------------------...--------......-----------.....------------------------------------------....._ Installer at......."-�_T. ._ .... _ .At.f '/! lZ tat.....-/ R............... ---�ftL.A- �A---------------•----...........---•---•---•---•-•-------------- has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... _7_-6 l ........... dated_............ e ! --__------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTR D AS AI GUARANTEE THAT THE SYSTEM Vy4L FUNCTION SATISFACTORY. DATE .....-�'•----..�.........._ / / ......... Inspector....... THE COMMONWEALTH OF MASSACHUSETTS r. -- BOARD OF - EALTHH 7� <,Yi 7 ( din OF............... ll,�.+ .�C...,c../-�c_ ...... . .- ..... N ..•.......--•---. FEE............... giopo#al Works 0151,11notrnr#ion "permit Permission is hereby granted....-,_... .... to Construct (X, ) or Repair ( ) an Individual Sewage Disposal System at No.:W.Y ....... 41�[ �'Mo Z- ........ !./ ---------••-----�-t-'•••� t_4/. . .....-•-- Street . 17-7 as shown on the application for Disposal Works Construction Permit o�7 .._ �T, Dated.............y a .•- Board ofx Health DATE------------9 a ........................... ............ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS C* _ COIL L08 f4'c. !,-PEAASTONE LOAM d FILL T I2'AX.1. DISTBOX 0MIN.•IIN... 1000 GAL. ! 1000— GAL. L SEPTIC I0 o�°,' PRECAST OR TANK 6 I��, BLOCK C D 0 !/ I, . • ° • SEEPAGE PIT ° ° )j ° �I�. • °• o ° °� q 20 MINIMUM .o, e 0 °I FOUNDATION I I 1` hE,24 I YP" WASHED STONE� / /ZI/a h- SCALE: I I�` I� Z�tQaCJ► .oar ✓Y4�p f r t, r 10�cor«+ FuaiwS %o TRe 2oA.irnrj•-L".� ot" T! .� a PQQC. RAYQ t t...Ccroc z....,v�.✓ r Cli s4 G\t 4q� 7=ts TEST BY : c.d WOC s+/i�.✓c�ar�4e./ TOWN INSPECTOR: BACKHOE OPERATOR : 'zc- 'S E`,, a q S•s. f•Ole TEST MADE ON ; /97-7 . M oc pgf��cs S/o_ P,r.v10 7-oa- f ROB EI f �,,, 0 uDAY R dwy . No, 20108ley 41= Q ,� O,SV�V�/ + �e A / s J p � J - 1� 41.2 l3la.p i3S, 1� ha-I%%.OF*f, i- � (s� �'ew.�.fl,�r Tip,✓ V O� RO RT F. E DA too p t4o.23741 /43 �, iti✓q� "` _ , Iopo 6AL / Q ice./ -rAup�,. � a v o, x ooll oe olo 1� w ,c :✓�� 13T VRESST-ve AMU t3 .ELEVATION SCHEDULE 17 I. INV. AT FOUNDATION / 5.6� PROPOSED SITE FLAW 2. INV. INTO SEPTIC TANK 47 N V 3. IN OUT OF SEPTIC TANK = �3Q �� 44; /1'13st:�lL,ea /Zip//� 4',ov$s , 4. 1NV. INTO DISTRIBUTION BOX - ✓4.110 p? SCALE: I°= ZC- S`t,T. 19 77 5. 1 NV. OUT OF DISTRIBUTION BOX , �3'.7'99 c— J L ry 0 6. INV INTO SEEPAGE PIT ' = l�✓'�.S'9 CAPE COD SURVEY CONSULTANTS 1 7. BOTTOM OF PIT It7.6,1c) ROUTE 132 HYANNIS, MASS. 8. BOTTOM OF STONE LAYER = 1L - 6`9 A DIVISION BOSTON SURVEY CONSULTANTS, INC. I