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HomeMy WebLinkAbout0020 BOG BERRY LANE - Health LOT #I BOG BERRY ROAD,-M-M. r" o yy Dv -2 Qo YY�0.�rsEur.�, YI/►► I (5 __ _ _ .__ __ - F. Commonwealth of Massachusetts D` f-DD'�'--OOa• ` Title 5 Official Inspection Form w. ! �,► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name -- information is Marstons Mills MA 02648 11-7-19 i required for every . page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information C54 fyaSb Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);l have personally inspected the sewage disposal system at theproperty 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 iY 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails _-,4w 11-7-19 nspectors 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. w`s 4 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 i 1 Commonwealth of Massachusetts r� Title 5 Official Inspection Form F�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `y °" . 4 1, 20 Bo BerryLn ,> Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 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 not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. Y g g 9 2) System Conditionally Passes:- El One or more system components as described in the "ConditionalPass" 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): r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 r I i, Commonwealth of Massachusetts ,w Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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 i y q p p g y 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 El ❑ 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 r r Commonwealth of Massachusetts 3 Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_.• ,6;/ 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 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 j. Commonwealth of Massachusetts 3 Title 5 Official Inspection Form I�t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 r Commonwealth of Massachusetts a 3 Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � :M 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town 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 aH 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? ® ❑ Wasthe 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)] t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I�;IFI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 33 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current.'residents: 4 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11-2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 1 , s Commonwealth of Massachusetts 3, Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments : . .a 4s. 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ 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: Owner----pumped 5-2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped!: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev,7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 1'8 I Commonwealth of Massachusetts r� 0 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln °roperty Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 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 l/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: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form I� w:� I�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bo Berry Ln_,•T, l' 9 ry Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills NIA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 12" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 4 ,` Commonwealth of Massachusetts lt� ;., Title 5 Official Inspection Form ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 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 r� Title 5 Official Inspection Form Sri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,> 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 t Commonwealth of Massachusetts 1� f Title 5 Official Inspection Fora hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: Infiltrators ❑ 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 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form 'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vic; Y:c 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrator field in good working order and empty at inspection with no sign cf back-up into d-box or surrounding stone. 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 C Commonwealth of Massachusetts .�� �� Title 5 Official Inspection Form I"I' I111 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town 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 Fora iQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 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 0 rp t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 A. Commonwealth of Massachusetts ,w Title 5 Official Inspection Fora C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r . .a r 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Bog Berry Ln Property Address Bill Cole Owner Owner's Name information is required for every Marstons Mills MA 02648 11-7-19 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. riv ® 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 I -- = --- ------ -- TORN()�;BM STABLE L(}Cg'f"iON 6M�/Y'Sy Lyt SEWAGE# /1 ✓ rS /r S ASSFSS{}R'S o`ti L4T` VILLAt�E Gc 3hISTALLERt 9A11► c� Oldl:NO SEPTIC TANK WMAC£'I'X ;��_. a 3 EAC>I11�TG FACI1�'� (ty{ (side) NO.OF�ET3tGC?NiS DULLOER OR-, P�R1IITDAEt3NffLNCE'DA'LE OP PA Distance Between the Feet M. Max�mtm AdNsted Crro�ndwater Table to the$ottom'of ieacting Faci{�ty Fir an webs.exist' Pnvat Qatar�upply.Well andLeag ► ( Y Feat, ou srta or vnttun 7AU fect df leading f�icy) Ede:o£Wetland and I.eactung#"aa ty(Lf ariy�vctlaiids east Fed with 300 feet df%. hiag Ftnyushed by: - - 17'(, Gera -ao ,6 11 �43/- a 5' 6-3 - a� TOWN OF BARNSTABLE LOCATION LDS I &, Tomi L4*16- SEWAGE # 1� VILLAGE Ma��5�o►.d5 lam` ASSESSOR'S MAP &ILOTTflu.D0 INSTALLER'S NAME&PHONE NO.'— SEPTIC TANK CAPACITY l S-2 b y LEACHING FACELITY: (type) � Frz� -r. .1 (size) fJ NO. OF BEDROOMS 3 r 2 BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: �a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 1` Feet Edge of Wetland and Leaching Facility(If any we exist within 300 feet of leaching facility) a Feet Furnished by r Aj� h -®a A q4'-6" 3 46' �''' f A j 18 '-aN Az- >7' 4" TOWN OF BARNSTABLE LOCATION GOT I &4- `Bvr. L4-�Ja- SEWAGE # 1 Q VILLAGE M OaSl js 041Lbs ASSESSOR'S MAP &ILOTC&,00 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IS D b p� LEACHING FACILITY: (type) IAA vr, (size) O NO.OF BEDROOMS BUILDER OR OWNER ��LE C��U✓��� PERMITDATE: _ 2�l1/98 COMPLIANCE DATE: -71l0198 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �� V No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 'PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,. MASSACHUSETTS Yes 01ppiication for Miqual *pgtem Construction Vertu Application fora Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / /-2-04 / y Owner's Name,Address and Tel.No. GeOV4 Assessor's Map/Parcel ¢4 0a7 Z Ins aller's Name.Address and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size 2 o 94 to sq. ft. Garbage Grinder( ) Other Type of Building vvb= No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 2..cs gallons. Plan Date //-/-2 -4 7 Number of sheets Revision Date Title Size of Septic Tank l S uc5 Type of S.A.S. Description of Soil O - A- 13 Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been iss by this Boar f Health. Signed ` Date 2 47 -9 0, Application Approved by Date Application Disapproved for the following reasons r II Permit No. —/0 Date Issued No. 9 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYicatiou for Mgoml *y5tem Con,5truction Vermit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / 1-'O /3a�Ly Owner's Name,Address and Tel.No. Assessor's Map/Parcel +¢ d07—Gp 7— Installer's Name,Addresyand Tel.No. Designer's Name,Address and Tel.No. 7 7-7 ,Q4.4— •t=.G_VC�/.lJto=iZ/t/G Type"of Building: ' Dwelling No. of Bedrooms 3 Lot Size 204+1.,, sq.ft. Garbage Grinder( ) Other Type of Building Wkl- No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3o gallons per day. Calculated daily flow 3 L.o gallons. Plan Date //-I? -9 7 Number of sheets l Revision Date Title Size.of Septic Tank Type of S.A.S. Description of Soil O - tit- 3 G ^,yx - 5:a0_J,> 1 6 l � e Nature of Repairs or Alterations(Answer,,when applicable) F' r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of h afore described on-site sewage disposal system x in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss e by this Boar f Health. Signed Date Application Approved by A55rDate 7,-Z 0-e/ Application Disapproved for the following reasons Permit No. - 1 f Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( Repaired ( )Upgraded( ) Abandoned( )by PrcAe C d& at Odc 45A"Y�i�,�E e l/lile -WAo-f W,/I L S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. M-/01_dated_ Installer 4 2C IV �r it-s Tip. Designer GL - The issuance of this permit shall not be construed as a guarantee that the syste will function as designed. Date -- l I() •qC�) Inspector �`� ---------------------------------------- No. $ /r?'�/ — Fee-�=. � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS 1=igpogar 6 stem Cougtruction Vermit Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon( ) System located at On fft_C'ex/?k /4r/,�, /fjf 9�i `�-�t� and as described in the above Application for,Disposal System Construction Permit. The applicant recognizes his/her duty to f 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 perinit. t Date: Z ^Z�/—g Approved by / � � l t►wu ul I�.�t'ntil.1hic I �� v J Department of Health,Safety,And Environmental Services Public Health Division Date 367 Main Street,Flyannis MA 02601 3 aAaN8TA8LR Time 4jj &,kn Fee j►lro�A�� Date Scheduled Soil Suitability Assessment for Sewage Disposal Performed By: {��� �T �tTu � n Witnessed By: LOCATION &`GE NERAL INPOIZIVIATION . Ile owner's Name Location Ad ress ( � � `w M k r((� Address'49 t IRXY- RO +!1��rN�S ��► / Engineer's Name ?-�•iZ,� Assessor's Map/Parcel: 4¢-oaf NEW CONSTRUCTION REPAIR Telephone 0 1 .f?^O -p 1) G �, ��J/ �T' l,� 1 Slopes(% ' S) Surface Stones ( 0-4 Land Use �� ��� Distances from: Open Water Body f R Possible Wet Area Z�J=r R Drinking Water Well /V4 n R Other Drainage Way_ R Property Llne _ SKETCH:(Street name,'dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) -PC>q 40\ pou Depth to Bedrock Parent material(geologic)rL�/k� �N Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face \ Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL:HIGH WAUR TABLE Method Used: in, Depth to soil mottles: In. Depth Observed standing in obs.hole: in. Groundwater Adjustment R Depth to weeping from side of obs.hole: Ad factor Adj.Groundwater Level Index Well N__•_•_._ •Rending Date: Index Well level I• _•__ •• PERCOLATION TEST bete CI Timm Observation fi Time at 9" — I tole# n�►I Time at 6" =- Depth of Perc S.'1 Q'QO Time(9"-6'1 Start Pre-soak Time© — End Prc-soak A) Z(O . v ZM ry t rY,►}' ZA }lrA ti 1O►>'b 10 Iv:L!e u IAl Rate Min./Inch J _ Site Failed: Additional Testing Needed(Y/N) Site Suitability Assessment: Site Passed Original: Public Health Division Observation Hole Data To Be Completed on Back----) Copy: Applicant k• 4 HOC # -* k _ D11,11,1• OBSF tVA'1'ION ROLE, LUCy toil Other soil'rexhtre Soil Color Depth rforn Soil I lorizon (Munsell) Surface(in.) MutQh,g (Structure,Stones,Ilmddercf. (USDA) S:oaslsle»cx.GrS1tAv l 06� '3j1 3u.. K t ppaual A k04 PEE EV 0[3s iWATION II0LC LUG hole# Xoil _ Soil Color SO other Ikptl,from Sol[Ilorizon S(U TextureSDA) (Munsell) Mottling (Structure,Stones,noulderes. Surface(in.) (U s)slsncy.'�afgyt(1—,—_ 4N�w 1 � loya- Nt- NoNG gN, 2a '�j LC)ttifM`; LP�Vp 1tOq12 G otho E ' DEEP 011SCRVA'I ioN IIOLC LOG hole# l CnIor Solt Other Dcptl,from Soil IInrizon S(USDx) SMunsell) Mottling (Slniclure,Stones,noulderes. Surrnce(in.) (USDA) ( • DE, EP OBSERVATION HOLE LOG IlolC # Soil Color Son other Depth from Soil l lorizon Soil'texture SMunsell Mottling (Sln,clurC.Stones,noulderes. Surface(in.) (USDA) ( ) �trncv Y•t7revcl) r floo I�Inc�trance Rate Mat)= Above 500 year nood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes 1 u feat t o[ rat rally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout 111e area proposed for the soil absorption system? im�_ If not,what is the depth of naturally occurring pervious material? ('ertlficatlon � v I certify that on N �i (date)1 have;passed the soil evaluator examination approved Department of Environmental Protection and that the above analysis was perfonned by me the required training,expertise and experience described in 310 CMR 15.017. i 1 � I i I 'ILG' �'J' i , ,�'-�" III-3• v'•� FYf"¢% - _ r....__ .._._ ' fwo Air LZZW- `'r"' GPM• �1• �-• -�-�� .;'i',--z�----: __. N - ' 1T -- -- - — - WIVE- 0'.w s-l d'GG• - -- } u14' I _ ixt� Irxf/` sre�i 1 I A" I - ----v1 — r---- n I ,p W- 41•.0 I c 0-If t ;M u-• . � � mow• ��_° • srr�' �____ rL�^�'/',per p� Gi�.l � ` Ll-,eLAI ' rtr � rr•F � ? 9rrsi �i gl _ _ �% Y — Rllen B. Osgood C.P.R.R. PR Row 735 134 Remote b-R Snndmich, MR 025f.3 1-508-833-5830 �A•1.E >� y G%f�`T l s5 s•�� �cfP� ,Te H.h—atere o�a �*a° 10°.in m sem�d loal caea rye adni.na. G`-r^�' gdCr.Allw R(HAS a P�V�6���Y be Md aspaufNa fa aRe aanmtiao-a Ilr r ' I ""`�r / o-�..e.....r. afire A�wviP�M aonsmietlu�.f'asY/n of Ole�eevlp h m Yee1A'�dalllOb d �f ,GLOM I�mp NOEL. / 4' the purchaser of these plans is responsible for casapli—with RU Sbb and loaf Codes sod ofdotaacea. Neither Atka&Osgood or paMcWating Designee may be held resPomble fa sCe=W'Iions of the use of thew dfawmga&=%conshuetioa.Purim of the&awv s is rapo nnue to VUifY AD elemmb of l+� / thew plans for design,soauacy and siae•prig to acdrel cmwhuetiao. lr AA, II Ian I �O P � Owe Co44 s T T WF 11 fu*s'� Po eftATI�I I I O+P I 3 I �¢)z�i��i _ _ I � Pam•'{I PH - 114A' I hI 44L�r A4W- flloApt- a I GAt Z- FA;f 010I. A t3t-} I I • -- FuwR�'r.xE-f�f�><a Fiµ.l�•�xob �l Rllen B. Osgood C.P.8.0. PO Bon 735 134 Route 6-0 • Q I -Sandwich, MR 82563 ��1.�G�"��� r �-�-+ ���;� ��I= �I�I GIZ-Ip �•�' 1-508-833-3830 WALE: rI I� APPROVED ar: DRAWN ar DATE:41,44.P"I Raveiro I�'� t DRAWMO NUNaxw �o. Az tr-'r vas• wuDeo oR Ro.�soo�wssswWr I . 6-A5 PIPS C-46C.K TU St'E IF THtll LAIJ 7bE (v101Jf-T) I r N o-f M Ol)SD . 3.� x :YoP r• wtJCJW a-(o'•{a,bElt a-ro"Nivy Q�T rOo2 - - ------— j \ _ 4"sofp 1+- }' ✓/ c 'Jc.. ; `I NfIJ. dl V cuR-u-y i i TO rcoo-- ZD15T5 . dr(�. W) v.T' g1ll I� yT wAIL ( - --� "7p GLti/\2 I,JIIOUJ-) - f3ViLD Ulp. To L'St AjJGVE /,t)/NDOCti It L I I f3W on)E LJILI }1 nnG qO,a 1 II rLunl C+6fC �+ �* ` ti CA" 1J0T GN A„)G E _ .. .. LL t.� t __ f' _ (G'�7" T'� C'J.LOW G — I --- /� M A G'2T 4'Ja p r I1 . bUILV SAF 1, /-'J D 1 INS IOE ��� ��a✓� . 3T 4J SHwH dlo•`OE 1'VRNR O a'ntt. ' I xOPTIDN4� Rt MI. POSTS , A'Aa A W�v1 1 1- .3 5T tE L SPA u i OAIL BLJ MAICL+ E%'�T71L- uP 1A1 . 5 °1J - $OPEN�-i REl15F GIt�.IJ 5 G Loll (` P4!n1iL-'..) WrfmT :: OA 11 S" DI TOLD Z�•7 CLIENT 7b RE L.oC.A'F a SPI t;ELq TR�nW,1- DDO'es� _ -� -t AL.A2N. Pfh \Aa3l Ag REQ, 1 - _ ,tl-N.,ST E.A (NTU CLGS T h FI0. rr. Si6L nJx A2Ou vb I N !-Ort Ns:ti Zbog ZAP F A:tE N T r-�*A l D-i:L . i J. 1 e � PAY �+Me$. 6A"1 { t aD�lr^71;rrshtJ �8•r/e!>/ , Mr, ,y Apr .,r`.'s. ....I..n_ .:..v.. ....... _.�......:. ..n., ... -. ... :.. --_ : Apr •.t, rf-v: • .. „� .Tm t r•: Y"+'P' }' -.q:l grit, l J' Z M, ,"gin Viz:. �?_ � s ,_ � ..�•, �. _ � - . . _. .. ...�..c.. .: ,.... . ,.... .. .. ,a.'t`i:- ...+ i,yy ,` Y ., .x_. ;^7,.wds. .. .. .'rsbs.._'r...aY:.•.. .._ S ' .Jn..... � iy .. �}' ,_••'SX , ^5 .. .. -4'.� e ��:i'-'___.•y„�. yyr,� ��.-�5tss1 '��S`.s'y9[$�"A�'d:�: rr....��. u .,.t.,i. :i•!:, ... THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA • Lot 2 T S K i Boq Berry Lane _. 50 ' wide 8 \ ti �0 7G.S Lot 1. ? 204]_6 SF - �1 82r _ -- ,' < __.__.-......_ / r i I (, 10 C'/rr `K. Open Space / j C 7t.• k7 -- ' •r Fmk Profiles no scale 1st 2 ' out of - ----. . D-B to he level ------ vent N nt r 7' rJ • 1`0 :Irrr - _ �r L' i . 7n�L' r `i. r ,. h I ` 3' Use 8-- high capacity infiltrators ! with 3 ' of stone on sides and Install a -_.. - -----.-. ---- _.� f i gas baffle middle as shown. � here 1 • _..� vent Septic design 1. i No. bedrooms 3 VsE ''; u N CAPAC f / - = BHA• =.T�.� Req. leaching 330 qpd Req.' tank 1500 gal 2Lj I c��ac� _ C7 0-7. t r�. i�� ��`J!•� � <J ti:_' L. •r_.,..r ..:vi x i l Leaching: area I5x :�Ox.74= 266:'.4:. F-- ----. _... . - F-4' 78.x2=l5b'x.74 = 1.1.5 .9 Total leaching 382 .0 gpd y i . Note: All work to conform to the minimum requirements of title v Site Plan of Land in .Marston Mills, MA For Dale Crowder Being lot• 1. as shown on a plan in book 444 page 15 Elevations are on NGVD Date Agent Barnstable board of health Scale 1"=30 ' Date 11-12-97 44 cl 007-002 All Cape Engineering Map p Harbor.. Road Test-pitP-9*i* Hyannis, MA 02601. Made .11-6-97 Wit J. Dunning No water encountered 'Perc:: Less 2 min per 1" T -P 1 T P 2 y t a,.3.' cnNc 7f.4 JRi ,\ra:` O' 4a /G•p 0 ••7• �a4My .�•�� 4:g' 7Ar9 �K '� ,•, 8"3Z• 77.4 32' Zo• 7¢.3 R°. t. ,A"� .� JUH .. V i "36 N . -_-�..l U 4 B � �,�� � � �•4�•Apt Lot 2 ga' Sk f z I -7 7 e l Bd k Bog Berry Lane ------------ 5 p ' wide _. _.. . - i = 3 '`-- VL • r 1 Lot 1 2041 6 SF T 7aC9 ,open Spade i Profiles no scale Fu4 �lst :2 i D B 'to be level vent ;. ji ". _,. �b JO IO• � f /4• ev- �'--j --� cvc> --•o f� oGr.:.4'c::7 - GL°CPO p .._. Sr , i / ♦ d i d ..�ro.t, L,SVEC. u •Use :: , high capacity infiltrators lnsta - �- - . 1-3 a _ J. 1 ;with:`3 ' of a'torie on side`s and : . as baffle _ . :middle -as shown. g ..' + 'h ere v 4 • . r Vent. _• d . Septic design No.- be I - drooms' 3 USE H I R'dq..., leachinq 3:3::0 gpd - 1 ... L t-�V Ica `a �'} ea.('� .: � ,. � .^ .r ll. ...•t C•I a al_ c ca c- =,c, r.K �. , rr �!P_...`?Tc�IV!:_..._ U -!_�'.c,1 .. _ .. . � __ i• -Reg.'tank 1500 9 .: rt f-heathing; area 4, - - -118x2-� 6 .74. 115 .4 -;Tote 'leach' ng: 382,.0; ;gpd ;. i + _ f. _-Notei*.All' work to conform murfi_ requirements ' the v Sit bf ti e Plan of Land in Marston Mill's,' MA r_3 Foi ;Dale Crowder , { _ r } Being lot 1 as shown on a plan in book 444 page 15 i Elovatibns are on NGVD ; _ - - Date Agent Barnstable board of health ; - Scale 1"-30 ' Date 11-12-97 i -. -Al l Cape. Engineering Map 4 pc1 :007-002 Harbor.. Road _ -- - t. ._- _go MA .0 601 _1 = t _ . . _ .'...:Hyannis, ,. • Made. 11=6-97 A Wit J. Diinning 'No--water- ;encountered - ess min per ..� A SAVO !� _ "7 • 9 t,owKy. i ca Y - i,iPll' G OF Ht Vn[i i2v^Er_' o� JUH 1 ` r :.i Gr E 1