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0065 BOG ROAD - Health
LRoadMills15 , ti* � o ��� 39 ' ' , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspectioq Form dated 611512000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: 65 Bog Rd Property Address Medeiros Owner's Name saa Owner's Address Marston Mills MA 02648 City/Town State Zip Code Date of Inspection: 12/1106 Date 2. Inspector: Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 Cityrrown State Zip Cope :508.272.6433 Telephone Number Certification Statement: f; I certify that I have personally inspected the sewage disposal system at this address and thafithe information reported below is true, accurate and complete as of the time of the inspection 1`he inspection was performed based on my training and experience in the proper function and maintenanFe f on site sewage disposal systems. I am a DEP approved system inspector pursuant to`Section''1 .340 of Title 5(310 CMR 15.000).The system: 'Cam ® Passes ❑ Conditionally Passes ❑ Failszq ❑ Needs urther Evaluation by the Local Approving Authority r a4zggg� - 1211106 InspectorY Signatu a 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 is a sharipo 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 DEP. The original should be sent to the§ystem owner and copies sent to the buyer, if applicable, and the approving authority. """'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in t4e.future under the same or different conditions of use. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 65 Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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: Pumping suggested every 2-3yrs to prolong the life of the system B) 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: n/a Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System t Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M A. Certification (cont.) 65Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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 ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with�10 CMR j 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water [. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a s@lt marsh Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Ri¢posal System f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 65 Bog Rd Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health(and Public Water Supplier, if Rny) 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 SASS 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 Out 50 feet or more from a private water supply well". Method used to determine distance: n/a This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free frojpp pollution from that facility 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 mwst be attached to this form. 3. Other: Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Qjsposal_System^ 41 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments o. Subsurface Sewage Disposal System Form A. Certification (cont.) 65 Bog Rd Property Address Marston Mills City/Town State ZipCodp Owner's Name Date of Inspection D)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 ❑ z 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 '/2 day flow El ® 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. El ® 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 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 great#r 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 Dgp, certified laboratory,for coliform bacteria and volatile organic compqunds indicates that the well is free from pollution from that facilitX�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.] Yes No ❑ ® 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. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage pisposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 65 Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a faFility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well' If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or oper*or of any large system considered a significant threat under Section E or failed under Section D shall"upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 65 Bog Rd Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: 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 G is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(0)l Title:5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 65 Bog Rd Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: I Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: o96upied DO Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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 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): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments a` Subsurface Sewage Disposal System Form M Sve� C. System Information (cont.) 65 Bog Rd Property Address Marston Mills CityTrown State Zip Cod@ Owner's Name Date of Inspection General Information Pumping Records: Source of information: 2.5 yrs ago per owner Was system pumped as part of the inspection? ❑ Ye§ ® No If yes, volume pumped: n/a gallons How was quantity pumped determined? Reason for pumping: 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information, 1987 per as built Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage pipposal-System^ f Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 65 Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100 feet Comments(on condition of joints, venting, evidence of leakage, etc.): no adverse conditions exist Septic Tank(locate on site plan): Depth below grade: 1'6" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: n/a years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Ye§ ❑ No certificate) Dimensions: 1000g Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle >1 To Scum thickness 6" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Title 5Template.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage[disposal System • I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Ar C. System Information (cont.) 65 Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, stry9tural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ Qther(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, str49tural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: n/a Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Title:5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Dipposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 65 Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: n/a Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the pipe Comments(note if box is level and distribution to outlets equal, any evidence of solidi parryover, any evidence of leakage into or out of box, etc.): No adverse conditions exist. D-Box is 2'6" below grade Pump Chamber(locate on site plan): working order: Yes No Pumps In o g ❑ R. Alarms in working order: ❑ Yes ❑ No Title,5Tem plate.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments M SV• Subsurface Sewage Disposal System Form C. System Information (cont.) 65 Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit is to grade w/a 2'6" riser. Static liquid level is 1'6" below inlet pipe. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Dipposal System Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M y+eJy C. System Information (cont.) 66 Bog Rd Property Address Marston Mills c4rrown State Zip Code Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration n/a 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 ref vegetation, etc.): Privy(locate on site plan): Materials of construction: n/a Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition gf vegetation, etc.): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 65 Bog Rd Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: Observed hole NGW at 12' Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Qipposal System r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r Subsurface Sewage Disposal System Form C. System Information (cont.) 65 Bog Rd Property Address Marston Mills Cityfrow n State Zip Code Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 400 feet. Locate where public water supply enters the building. i F� •� � �r< a A q � c Title 5Template.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewagg Qipposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog road, Marstons Mills { Property Address — - Donna M. Medelros Owner Owners Name urforrnatf°°is Marstons Mills MA 02648 09/16/2010 requited for Crrylfown state Zip Code Date of Iron Inspection results must be subm" on this form.Inspection forms may not be altered in any way.Please see completeness chec list at the end of the form. Important When f76ng out A. General In#ormation forms an the n I 1 computer,use 1 Inspector only the tab key to move your Reid C. Ellis cursor-do not Name of Igor use the return key. Ellis Brothers Const Company Name 23 Enterprise Road, P.O.Box 59 Company Address Yarmouth Port, MA 02675 n City/Town ! State Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification 1 cerlify that I have personally in the sewage disposal system at this address and that the ! information reported below is true,acc irate and complete as of the time of the inspection.The inspection was perforated based on my training a rid experience in the proper function and maintenance of on site sewage disposal systems. I am a DE PI approved system inspector pursuant to Section 15.340 of True 5(3 CMR 15.000).The system: passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -4 } 0 0 '44h, nspec tes Signature Date ►-' 4 The system inspector shall subm-it�a Dopy of this inspection report to the Approving Au_Oft Board of Health or DEP)within 30 days of completing this inspection. If the system is a share_d*ystem or has a design flow of 10,000 gpd orb greater,the inspector and the system owner shall*bmitoe report to the appropriate regional office of the DEP.The original should be sent to the meter o wner and copies sent to the buyer,if apQlicable, and the approving authority. ) rn F; 1 *•*'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 condition of use. MIS.W= i� Tift 5 tkfiaet kapedw Font Subs mbw Sewage Disposal 1 of 17 i i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 65 Bog Road, Marston Mills M _ Pmmrty Address Donna M. Medeiros Owner owner's Name information is required for Marston Mills MA 02648 09/16/2010 every page. CityRown state Zip Cade Date of inspection B. Cerfficafion (cant) Inspection Summary: Check A,B,C,D or E f always complete all of Section D A) System Passes: V& I have not four 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: B) System Conditionally Passes: // � ❑ One or more system components as d bed in the"Conditional Pass"section need to be replaced or repaired.The system,upon cc inpletion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes ,"no"or Onot determine "(Y, N,ND)for the following statements. if"not determined,"please explain. The septic tank is metal and over 20 years o!d I or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiftr ition or exfillration or tank failure is imminent System will pass inspection if the existing tank is repla md with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it iE structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less tha 120 years old is available. ❑ Y ❑ N ❑ ND(Explain t Blowy LILM-M, rftsoMCWb FOM&tWurfma Stmap OLVOsal sysftn-Pap 2orn Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 65 Bog Road, Marstons Mills aioi enr Aar Donna M. Medeiros Owner Owner's Name require dfo Marston Mills MA 02648 09116P1010 require!for every page. City/Townstate4p Code Dare of Inspection B. Certification (coat.) B) System Conditionally Passes(cunt.): __00 ❑ Observation of sewage backup or break i iut or high static water level in the distribution box due to broken or obstructed pipe(s)or due to 3 broken,settled or uneven distribution box. System will pass inspection if(with approval of Boart 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 rep ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approv 31 of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I.100W C) Further Evaluation is Required by thWBoard of Health: _ ❑ Conditions exist which require further a luation by the Board of Health in order to determine if the system is failing to protect public h Ith,safety or the environment. 1. System will pass unless Board of itir determines in accordance with 310 CMR 15.303(1)(b)that the system is not fu Wsoning in a manner which will protwA public health, safety and the environment: ❑ Cesspool or privy is within 50 ft et of a surface water ❑ Cesspool or privy is within 50 t of a bordering vegetated wetland or a salt marsh t5ms•09= T�65F>M1 MVBCWn Force SLOWt s&-MW Wqwsal System'Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments E 2 65 Bog Road, Marston Mills Property Address Donna M. Medelros Owner Owners Name information is required for Marston Mills MA 02648 09/16/2010 every page- cr'ty/rown state Tap Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of eatth(and Public Water Supplier,if any) determines that the system is function ng in a manner that protects the public health, safety and environment ❑ The system has a septic tank ane soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tbribulary to a surface water supply. ❑ The system has a septic tank a SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS ar I 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 analysi s, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: - Yes No ❑ Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow t5-t-ON8 Tft 5 oar kWOfmn wM&ft=%W saw OMPOSal syStem-Page 4 or 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 -9 65 Bog Road, Marstons Mills Property Address Donna M. Medelros Owner Owner's(dame information is required for Marstons Milts NIA 02648 09/16/2010 every page. Ciiy/Town State Zio Code [date of Inspection B. Certifcation (cant) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped_ ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ 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 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 N 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 searing a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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 con the Board of Health to determine what will be necessary to correct the ` E) Large Systems: To be considered a is 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 es"or"no°to each of the following,in addition to the questions in Section D. Yes No ❑ . ❑ the system is within 4 feet of a surface drinking water supply e ❑ ❑ the system is within 2 feet of a tributary to a surface drinking water supply El ❑ the system is located i a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a ped Zone 11 of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered"yes'in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department t5im•09= rft 5 0MCW knpevfim Facie&6M13oe Sex9e D40SEd SyS em.Page 5 or 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog Road, Marstons Mills Property Address Donna M. Medelros Owner Owner's Name require t b � Marston Mills MA 02648 09/16/2010 required for every page. cttyrrown State Zip Code Date of hmpection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: 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, chiding 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? El information the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ( ❑ Existing information. For example,a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actuaQ- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): C-, t5im•W= Tilt 5OMCW Wqxwffm Fa m SubufffaW S&&Wo Disposal system•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Severe Disposal System Fenn-Not for Voluntary Assessments 65 Bog Road, Marston Mills Property Address Donna M. Medelros Owner Owner's(dame require fo is Marston Mills MA 02648 09/1612010 required for every page- Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Lid Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ;No Laundry system inspected? El Seasonal use? El Yes Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: -- ate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15-203): Gallons perday C91d) Basis of design flow(seatstpersons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 5ns•OW08 re 5 OfSciat man Fomc stftunrace Sewage Disposal system•Page 7 or 17 nmonwealth of SSachuseft _ Title 5 Official Inspection Form Subsurface Sewage©dal SystemForm-Not for Voluntary Assessments %y 65 Bog Road, Marstons Mills Property Address Donna M. Medetros Omer Owner's Name information is Marstons Mills MA 02648 09/1612010 required for Stafe zip Rafe of it pedion every page. Citylrawn D. System information (core) Last date of occupancy/use: Date Other(describe below): General lnforrrration Pumping Records: ` Source of information: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: PR How was quantity pumped determined? Reason for pumping: Type o 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 tlA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Tole 5 fliSdal hspedian Fwm:Subswfaoe Sewage Disposal system'Page a of 17 t5ins•03/l)t3 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 66 Bog Road, Marstons Mills Property Address Donna M_ Medelros Owner Owner's Name information is required for Marston Mills MA 02648 09/16/2010 every page. City/town state Zip Code Date of Inspection D. System Information (cons-) Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes VNO Building Sewer(locate on site plan): Depth below grade: feet Material of construction.- cast iron [f 40 PVC ❑other(explain).- Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage c-)- � r z Septic Tank(locate on site plan): , Depth below grade: a14- -- �s c Material of construction: ZI concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) //XI f tank is 1,list Is a confirm y a Certificate oVp e?(aVch copy of rtificate) ❑ Ye ❑ Dimensions: Sludge depth: is ins•as= 1 rft 5 0 fiction form:SubsuRace Sewege oispow system-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog Road, Marstons Milts Property Address Donna M. Medelros Owner Owner's Name j information is Marston Mills i1 MA 02648 09/16/2010 required for t every page. CitylTovrn State ZP Code Date of Inspection D. System Information (colt) Septic Tank(coat) , 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 topttom of outlet tee or baffle How were dimensions determined? - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related outlet invert,evidence of leakage,etc : i .�- - C' Grease Trap(locate on site plan): Depth below grade: l feet i Material of construction: ❑concrete ❑metal fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tL or baffle Distance from bottom of scum to bottom Of tlet tee or baffle Date of last pumping: Date • Title 5 Otftaat pispection Fom Subsurface Sewage Disposal System•Page 10 of 11 I ' Commonwealth of Massachusetts Title 5 Official Inspection !Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog Road, Marston Milts Property Address Donna M. Medelros Owner Owner's Name information is Marston Mills MA 02648 09/16/2010 required for stae Zip code Date of Inspection every page. City/To" 1 D. System Information (co t) 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 Tight or Holding Tank(tank mus�be e t time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: r Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order_ ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float s itches,etc.): ---------------------------- F *Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No Tnfe,5 Off!oUmpecMForm subsurrace Sewage oispoael system.Pegg 11 of 17 f5irts-09108 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog Road, Marston WIS Property Address Donna M. Medelros Omer Owner's Name information is Marston Mills MA 02648 09/16/2010 required for every Page- CitylTown Inspection State ZO Code pate of D. System Information (Cci io Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): C f CLA T Pump Chamber(locate on site pl6n): Pumps in working order_ El Yes ❑ No Alarms in working order ' ❑ Yes ❑ No Comments(note condition of pum p chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System(SAS)(locate on site plan, excavation not required): if SAS not located, explain why: 15ins•OW8 y1ft 5 OffIeWtnspectimEarrrr Suter S&Njq;e D405W Stem-Page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme-Not for Voluntary Assessments 65 Bog Road, Marstons Wills Property Address Donna M. Medelros Owner Owner's Name requir required for is Marstons Mills MA 02648 09/16/2010 required for every page. Cityrrmvn state Zip Code Date of Inspection D. System Information (coif.) /a `= Type leaching pits number ❑ leaching chambers number ❑ leaching galleries ( number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of pondiing,damp soil, condition of ZNP < / t aj AO A✓s ,� 'C 0L5�; Cesspools(cesspool must be pum as, of inspection)(locate on site plan): Number and configuration l Depth—top of liquid to inlet invert; Depth of solids layer Depth of scum layer Dimensions of cesspool l i I Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No t5ins^0310f3 Tto s offiw kweebw FornC sown lam S Daposat system•Page 13 of 17 i f Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog Road, Marstons Mills Propetty Address Donna M. Medelros Owner Owner's{Name information is Marstons Mills MA 02648 09/16/2010 required for every page. C4rrown State Tip Code Date of Inspection D. System Information (colt.) 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,tigns of hyc raulic failure, level of ponding,condition of vegetation, etc.): I t t } t5ins•09J08 Ft�5 ofBdar inspection FaM St taface Sewage Disposal System-Page 14 or 17 j: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog Road, Marston Mills Property Address Donna M. Medelros Owner Owners Name infnm,ation is MarstonS Mitts MA 02648 09/16/2010 required for every page. City/To" state Zip Code Elate of tnspec ion - D. System Information (cant.) Sketch Of Sewage Disposal S : Provide a view of the sewage disposal system, including ties to at least two permanent referen=ndmarks or benchmarks. Locate all wells within 100 feet Locate wh public water supply enters t e building.Check one of the boxes below. i hand-sketch in the area below ❑ drawing attached separately JoW a' �.� s l 13, - 1:aj f7 t5ins•09W i TWe 5 Offickd Inspectim Foes[Stbrrace Sewage Disposal System-Page 15 of 17 f , Commonwealth of Massachus?tts Title 5 Official lnopection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Bog Road, Marston Mills Property Address Donna M. Medelros Owner Owner's Name information is Marston Mitzi i MA 02648 09/16/2010 required for state Zip Code Date of Inspection every page_ Citylrown I D. System Information (co ) Site Exam: ❑ Check Slope . r`i�. ❑ Surface water e9AI ❑ Check cellar �� ❑ Shallow wells 1 Estimated depth to high ground water Please indicate all methods used to determine the high ground water elevation: i ❑ Obtained from system esign plans on record if checked,date of de4ign plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local exjavators, installers-(attach documentation) Accessed USGS``database-explain: 4d/%J ,---You must describe how you established the high ground water elevation: s3 ij !Lf �6 F i Before filing this inspection Report,please see Report Completeness Checklist on next page. Tfe 5 offidW Inspection Form Subsurface Sewage Disposal System-Page 16 of 17 t5ins•09= { Commonwealth of Massachu tts - _ Title 5 Official Inspection Form Subsurface Sewaue®i-1 Svstem Fortre-11tOt for Voluntary Assessments 65 Bog Road, Marstons Mills Property Address Donna M. Medeiros Owner Owner's Name requir reqtonuired is Marstons Mills MA 02648 09/16/2010 required for every page. Citylrown Istafe ZIP Code Date of tnspecfion E. 7,� ort Completeness Checklist pection Summary:A, B, C, D,or E checked I spection Summary D(Syste Failure Criteria Applicable to All Systems)completed stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i 1 tt 15iru•>)91oB Title 5 Official tree Fam Submsface Sewage Disposal System•Page 17 of 11 f Al CERTIFICATE OF ANALYSIS Page: 1 ,ems ti .. Barnstable County Health Laboratory Report Prepared For: Report Dated: 9/17/2010 Reid C.Ellis Ellis Brothers Construction Order No.: G1059831I P O Box 59 Yarmouthport, MA 02675 fi Laboratory ID#: 1059831-01 Description: Water-Drinking Water Sample#: Sampling Location: 65 Bog Rd.Marston Mills,MA Collected: 9/13/2010 Collected by: RL Ellis Received: 9/13/2010 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.34 mg/L 0.10 10 EPA 300.0 9/13/2010 Copper 0.19 mg/L 0.010 1.3 EPA 200.8 9/16/2010 Iron ND mg/L 0.25 0.3 EPA 200.8 9/16/2010 Sodium 20 mg/L 0.25 20 EPA 200.8 9/16/2010 Total Coliform Absent P/A 0 0 SM9223 9/13/2010 Conductance 55 umohs/cm 2.0 EPA 120.1 9/13/2010 pH 6,5 pH-units 0 SM 4500 H-B 9/13/2010 Sodium level is at the maximum contaminant level. Those on a low sodium diet may wish to consult a physician.l Attached please find the laboratory certified parameter list. Approved By: ` (Lab rector) —7 O c) SEPFKcCD By ➢-_. .�... �3 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE LOCATION ® SEWAGE # 7- o h VILLAGE ' r ASSESSOR'S MAP & LOT �2� l INSTALLER'S NAME & PHONE NO. CY� P SEPTIC TANK CAPACITY 0O C2 r LEACHING FACILITY:(type)^/6 0 U 1 (sue) NO. OF BEDROOMS 2 PRfIVATE WE QR PUBLIC WATER BUILDER OR OWNER r I Ole �Vl� DATE PERMIT ISSUED: :DATE .COMPLIANCE ISSUED: w%i-e, z VARIANCE GRANTED: Yes No �w �1 ` t .� j y� THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTE-! S ------.--- 0 ..._ ...Q.. ..... OF..... .. ... i , ...� .................. Appliration for Disposal Works (foustrnr#iun rumit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at` W .....�2 .� f�_...... La p'----'----•--- -----------------„ ss ..................... or Lo................................................ No. ....................... ............... ...r2......... -4 der 1, Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................ . W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. 0� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................. Depth........... Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...................... .- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_---_____-__---_____ M --•----•--•-•-------------•---•------•-••-----•-•-•--------........----------- .._..... O Description of Soil.. -... ---------------------------------------------------- ...W .. .... W UN f Re airs or Alter gio s—Answ r when a plicabl . fit ____... 15 7 :.:._.. � w ': , �--------------------------------------------•--------------------------------.------ A eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIli LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ued the bo d health. - Signed e ✓ �r /--.... ... - Jate Application Approved By........-------..... -------•��........................................................ ----------------- - ---- ------ Date Application Disapproved for the following reasons:------•--------•--------------------------------------------- = ......-••-•-----------------------------•-•-••-••----------------•------------------•-----------------------•-------------------------•-------------------------------------------------•---•----------- / Date Permit No........ ..._....7. ... ...�® -. Issued............. .!-----a --- . .-. -_ 6� Date THE COMMONWEALTH OF MASSACHUSETTS BOARQ-,,,OF HEALTH ?.........._OF....� /9...� Appliratinn for Disposal Works Tonstrnrtiun runtit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System ate__ ��!!_- .....y .�_......_..... ✓lJ. ........ F......................... /.!J.- �.:+..t...���. !.L...��...................... Locatio s ... --.. , —�°� or Lot No. _C. .............•-•-•-•--.....---• 5 ... d�s Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----•------------------------------•--•----------------•••------------------•-------------------•---•--•---------------..........---........-------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L=.1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ----------•--------------------•-------•-------------------••--•-------•......--•--•---•--•--_.... ........................................................ 0 Description of Soil------------•--- = Q ;' 1 f �' . J }U ---------------------------------------------------- (> -•---•----- `--- . ... 21....! ----------------- =.� -•-••- -•---------•----------------------•-------------•----------•---- W x U N�t�of Repairs Alte atio s—Answ r whenpplicab e _f _.__... _t`_`� . ?_____-_ _.~�...� _-• .... 1. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITiE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ue th�e„bo rd health. .�.. =_. Signed;'��'`�L -�`� ..1 f.��1 . f r. ,� "".�„_.e... ;r.c 'L-.,"`_' ----_-.__..._ ...:.::'c� lam A lication Approved B " Date Application Disapproved for the following reasons:................................................................................................................ .........-•-----------------------------------------------`..--•---•------•--•----------•--------••--------•---------------------•-----•--•---------......--------------•-•••----------••------••------- ,__. Date Permit No------ ........................ .. Issued............ --._ Date THE COMMONWEALTH OF MASSACHUSETTS r' BOAR —OF HEALTH ................OF. /.... ................. t�..In.19 (Intifiratr of TnntpliFanrr THIS ,TQ CERIT-�Y, That the Individual ewage Disposal System-constructed s ( ) or Repaired . by..... =----••--....�..1.... ��.. 4_t...���`............................................................./ .." / .� ` /�I at_._.f_.. ;� — '� ------- y�' ., ......................................... has been installed in acco d ce with the provisions of TIT E 5 of The State Sanitary Code as described in the application for Disposal � rks Construction Permit No......................................... dated-.--------...................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... ." _' ......................... Inspector......................... . o! THE COMMONWEALTH OF MASSACHUSETTS BOARD--)OF HEALTH kh FEE.....:........... Disposal lVorhp Tan o rudwi' n rrnti# Permission, is herebyranted..........r_. . "...-✓.�.......__.... to Construct ) or Repair (` an Individual Sewage isposal Syst f atNo.... -- ----------- U �. .1 ... j.4 ------------------------------------------------------ Street i_ ? fd as shown on the application or Disposal Works Construction_Permit.-No--.—_....__._' Dated.....��....r`.-....................... ---------------------•---..--...•-•------- ` 7_ (�-'� ,'" Board of Health •�-,.,,•- DATE..... ------------••-•-••---• ................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS' i TOWN OF BARNSTABLE :LOCATION (30 SEWAGE # 7 VILLAGE ASSESSOR'S MAP S3 LOT�` ! dNSTALLER'S NAME 6z PHONE NO. IG P .SEPTIC TANK CAPACITY �� d jLEACHING FACILITY:(type) e)a 4 (size) NO. OF BEDROOMS � _ PRIVATE YUL OR PUBLIC WATER BUILDER OR OWNER 6We 2 �. r DATE.PERMIT ISSUED: DATE .COUPLIANCE ISSUED: 1.14-6 h 7 -- 'VARIANCE GRANTED:. Yes No 1 �3 1 EXISTING SEPTIC SYSTEM PER TOWN AS BUILT CARD ASSESSORS MAP 45 PARCEL 15 DATED 8/10/1987 ZONING DISTRICT: RIF 771.00 SITE IS LOCATED WITHIN GROUND WATER PROTECTION DISTRICT MIN. FRONT SETBACK 30' MIN. SIDE SETBACK 15' MIN. REAR SETBACK 15' "LOT AREA 28,075t SF �� —� 25000, ° o �, — 000 F SHED o\pNcF GRAVEL o DRIVE AND PARKING N ��• , ICI DECK S TO O `L ROCK RET. WALL WELL HOUSE \ ®w s\ 0v DCE #15-267 BULDING PLOT PLAN PREPARED EXCLUSIVELY FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT, NOT FOR ANY OTHER USE OFMgssq� off 508-362-4541 AT woe DANIE� fax 508 362-9880 A 65 BOO ROAD u OJALA c«�h c c7p e en qir�c e rin�, inc. 1diARSTONS MILLS, MASS. �No.40980� PREPARED FOR: 0 essko Cl VIL ENGINEERS qNo s Rv ° LAND SURVEYORS DAVID MAKI <20t 939 Main Street — YARMOUTHPORT, MASS. SCALE 1" = 30' DATE OCTOBER 1, 2015 - DATE REG. LAND SURVEYOR 5 C�ec . 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WALL y� WELL HOUSE \ 0 s\ awf "��.. \\SERVER\Land Projects 2007\15-267 MAKI\dwg\15-267 MAKI.dwg, Model, 2/29/2016 10:27:55 AM, Letter, 1:30 �7 ova School \ Barn O ` Locus LOT EA Rig 28,07 SF o ��O OroVei / 71 A450 he Shed �o -C� -60 6j `G dent LOCUS MAP — �e�\p 6, // Q► SCALE 1"=2000't �2 ASSESSORS MAP 45 PARCEL 15 �^' q- // LOCUS IS WITHIN FEMA FLOOD ZONE X 1,5 \� r° \\ 00 DATUM: NAVD '88 Scale: 1 = 30 2s roc �6 �lSLog. ADQN7f, ' \ �� / �/ ZONING SUMMARY e TOF = 77.0 0 15 30 45 60 75 FEET 'CIO>> !y� // ZONING DISTRICT: RF DISTRICT MIN. LOT SIZE 43,560 S.F.* SHRUBS OR GUARD 21 ��`� MIN. LOT FRONTAGE 150' IF WALKWAY WITHIN a rn MIN. FRONT SETBACK 30 2' OF WALL o' MIN. SIDE SETBACK 15' MIN. REAR SETBACK 15' ell ou a NOTES MAX. BUILDING HEIGHT 30' SITE IS LOCATED WITHIN THE RESOURCE TOP OF WALL // 1. DATUM IS NAVD88 PROTECTON OVERLAY DISTRICT ELEV 72.5 6" LOAM AND SEED OR // 2. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT'TO SITE IS LOCATED WITHIN THE 3" PINE BARK MULCH // BE USED FOR LOT LINE STAKING OR ANY OTHER GROUNDWATER PROTECTION DISTRICT 1*01 PURPOSE. V. � i REFERENCES // 3. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING LONDON BOULDER — I_ DIGSAFE 1-888-344-7233 AND VERIFYING THE DEED BOOK 24926 PAGE 187 CAP BOULDER ——— - _ _- _ - _ - 111-III-III-III-III=III=III=III=III=III- // CAT10N OF ALL UNDERGROUND & OVERHEAD UTILITIES PLAN BOOK 461 PAGE 99 48"x18"x38" _ LO ...................................................... = 1=1 I I=1 I I-111-1 11=1 11=1 I�I 11=1 11=1 11=1 11=1 11-1 (OR CAP BLOCK — — — — III-III=III—III—III—III-III-IiI—I — -- PRIOR TO COMMENCEMENT OF WORK. 40"x6"x34") =III=III=III=i — _� 4. EXISTING SEPTIC LOCATION PER TIE—CARD ON FILE WITH TOWN. 5. GUTTERS AND DOWNSPOUTS TO BE DIRECTED TO LONDON BOULDER + DRYWELLS OR ROOF DRIP LINES TO STONE TRENCHES. PLOT PLAN FULL BOULDER 48"x18"x42" CLEAN GRANULAR BACKFILL OF GROUND VARIES 65 BOG ROAD Z� _ 1' WIDTH FREE DRAINING �� 'ic jNOFMti MARSTONS MILLS BURY DEPTH CDg GRANULAR BACKFILL �� DANIELA. yG �� SSq 6" MINIMUM _ c; OJALA o` DANIEL ctiG ivz off 508-362-4541 t� s PREPARED FOR fax 508-362-9880 CIVIL o A. downcape.coIm © -o No.46502 OJALA U' CRUSHED STONE LEVELING PAD 1'0 -p �Q �� .6 No.40980 DAVID MAKI 42 MEDIUM COARSE GRAVEL BASE down cope engineering mc. � 'F G/STE p T- '0-/ E civi/ engineers s ( lq s°Fss , �� RETAINING WALL CROSS SECTION land surveyors 1 -t1-�w u_�� = f O NO 11, 2018 � 939 Main Street ( Rte sq REV.: OVEEMBER 20, 2018 > 5-267 NOT TO SCALE YARMOUTHPORT MA 02675 DATE DANIEL A. OJALA, P.L.S. REV.: NOVEMBER 27, 2018 1 cow ova CONTRACTOR SHALL BE RESPONSIBLE FOR CONTACTING DIG—SAFE (1-800-344-7233) AND VERIFYING THE LOCATIONS OF ALL sch001 UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. Locus Ricer Ro' n CD LOCUS MAP SCALE 1"=2000'f Bom I O ` / ASSESSORS MAP 45 PARCEL 15 LOT EA LOCUS IS WITHIN FEMA FLOOD ZONE X 28,07 SF DATUM: NAVD '88 O 65 Gr°Ve! ripe ZONING SUMMARY he WQY d9 CO ZONING DISTRICT: RF DISTRICT Shed �G den MIN. LOT SIZE 43,560 S.F.* / MIN. LOT FRONTAGE 150' MIN. FRONT SETBACK 30' MIN. SIDE SETBACK 15' 72 Exist. // 0� MIN. REAR SETBACK 15' A" Dwell. MAX. BUILDING HEIGHT 30' OO SITE I LOCATED WITHIN THE RESOURCE 5 \ O' PROTECTION 2S too '6 Prop. SITE IS LOCATED WITHIN THE e Add'n. e / GROUNDWATER PROTECTION DISTRICT ,9` REFERENCES DEED BOOK 24926 PAGE 187 01 PLAN BOOK 461 PAGE 99 ell ou e PLOT PLAN OF 65 BOG ROAD off 508-362-4541 `,��"l- Sc fox 508-362-9880 MARSTONS MILLS I downcope.com © -, PREPARED FOR dOWN cape engineering, inc. civil engineers DAVID MAKI Scale:1 30/and surveyors 939 Main Street Rte 6A ,. OCTOBER 11 2018 i Q� Y YARMOUTHPORT MA 02675 0 15 30 45 60 75 FEET ��`� " DATE DANIEL A. OJALA, P.L.S. 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