HomeMy WebLinkAbout0085 BOG ROAD - Health 85 BOG-""' �t `1VIARSTUNS MILLS
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�-\ COMMONWEALTH OF MASSACHUSETTS /moo
u EXECUTIVE OFFICE OF EIaT`VI tJ "�\BL
IONMEN 'AL AFFAIR
DEPARTMENT OF ENV Q IT �AL
U�Nt�FT „ „ l()TECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2
Owner's Name:
Owner's Address:
Date of Inspection: �1
Name of Inspect please print) (` ; (id
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Company,Nam — /�,,�"
Mailin;Address:
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Telephone Number:�'09-1
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
J Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fa'is
Inspector's Signature: Date:
The system inspector shall mit 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 shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection aed under the conditions of use at that
tme. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 , page 1
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Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
Property Address: as
Owner: _
Date of I pe Ion; :
Inspection Summary: Check A,B,C,D or E./ALWAYS complete_all of Section D
A. System Passes:
I/ I have not found any information wh_ch 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 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,Nyill pass.
Answer yes,no or not determined(Y,N ND e in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over20.vears old*or the septic tank(whether metal or not)Js 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-t 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:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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:
2
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Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ` g
Owner
Date of.I spe ion:
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.
I. 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:
— Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if 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
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 coliform
bacteria and volatile organic compounds indicates that the well i= free from 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 must be attached to this form.
3. Other:
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Page 4 of 11
O.FFICIAL.INSPECTION FORM—.NOT'FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Propert Address:
Ownen ,
Date of nsp ction: ®J
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes NoJ
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
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 r available volume is less than / da flow
q
o z o
P P Y
_ Required pumping more than 4 times in the"last year NOT due to clogged or obstructed pipe(s).Number '
off"times pumped
Any portion of the SAS, cesspoz)] 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 accept ble water quality analysis.]This system passes if the well.water analysis,
performed at a DEP certdied laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence"of ammonia
nitrogen and nitrate nitrogen is equal to or less than ppm; provided that no•other failure criteria
,( are triggered. A copy of the analysis must be attached to this form.]
S"V (Yes/No)The system fails.I have determined that one or more of the.above failure criteria exist as
described in 310 CMR 15303,therefore the system fails. The system owner should'contact the.Board of
Health.to determine what will be necessary to correct the failure.
E. 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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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
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
11,314..The system owner:should contact the appropriate regional office of the Department.
Page 5 of l.1
OFFICIAL INSPECTION FORM NOT FOR VO L UN TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner.•
v
Date of In ect' n:
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Year 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-ecently 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 in_erior of-the tank inspected
p ed 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 owne-)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:
Ye no
J 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(3)(b)]
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Page 6 of 11
F
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM:INFORMATION
Property Address: r 4
Owner:
Date of I spec, ion: 9j
FLOW CONDITIONS
RESIDENTIAL.
Number of bedrooms(design): 1 Nurnber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd_x#of bedrooms): ,. t
Number of current residents: n) ,
Does residence have.a garbage grinder{yes or no) /V
: 0
Is laundry on a separate sewage system(y s or no):)Z f if yes separate inspection.required]
Laundry system inspected(.yes.or no): �
Seasonal use: es or no : 0
(y )
Water meter readings, if av ilable(last 2 years usage(gpd)): G(
Sump pump(yes or no):
Last,date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design. flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc..):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records.Source of information:42,lrntjoLlx� t �
Was system pumped as rart.of the •nspe-cty n(yes or no),/
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TY 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 c in nents, ate.i s led if kno n) and source of information:
AA
Were.sewage odors detected when arriving at the site(yes or no
6
Page 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION(cor_tinued)
Property Address:
Owner:
Date of I sp ion: <—
BUILDING SEWER(locate on site plan)
Depth below:grade:
Materials of construction: - .cast iron _40 PVC_other(explain):
Distance from private water.supply well or suction line:
Comments(on condition of joints, venting, evidence of leakage, etc.):
i
SEPTIC TANK: (locate on site plan)
Depth below grade: I c�
Material of construction: . ncrete.metal fiberglass_polyethylene
other(explain) _
If tank is metal list age:— Is age confirmed by a Certificate of Compliance certificate) P (yes or no):_(attach a copy of
Dimensions: fD� ` `X j .
Sludge depth:Z<t
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: 7-
Distance from.bottom of scum to bottom of outlet tee or baffle: /
How were dimensions determined: _. d .
Comments-
,(on pumping recommendati ns, inle and outlet tee or baffle condition, structural integrity, liquid levels
elated to outlet invert,a idence of leakage,etc
GREASE TRA%(locate on site plan)
Depth below grade:_
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 frombottom of scum to bottom'of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle cctdition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL.INSPECTION.FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 4
Owner. sAUAi
Date of nsp tion: klotol (, ? .r
TIGHT or HOLDING TANK f tank must be pumped at time of inspection)(locate on.site plan)
Depth below grade:
Material of construction: concrete metal fiber-lass._polyethylene other(explain);
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working o-der.(yes or no)c
Date of last pumping:
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 inve�tjj llp�
Comments note if box is level and distributioj;
an equal,.any evidence of solids carryover,any evidence of
eakage into gr out of bo ,e
PUMP CHAMBER(locate on site plan).
Pumps in.working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances; etc.):
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Paoe 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Proper t ddress:
Owne i
A14
Date of sp ion:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers,number-
leaching galleries, number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
--.innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
et ):
/f
y// OIL .�
CESSPOOLS/(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth"—top ofliquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspools
Materials of construction:
Indication of.groundwater inflow(yes or no):
Comments(note condition-of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc:):
PRIVY. (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of pording,condition of vegetation, etc.): -
9
Page 1.0 of 1.1
„OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
l d`/1l A
Owner:
Date of I spe on:
7
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=00 feet.Locate where public water supply enters the building.
(� go l n
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Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
A'A
Owner:
Date of I p on: 0
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated.depth to ground water S feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of desian plan reviewed:
Observed site(abutting property/observation hole within 150 feet :)f 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:
�A y
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Permit Number:
- Date:_
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: `t ✓� pQ /"�� MS
Owner: /� e / Lot No.
Address:
Contractor: %P9J`7�Q � �jlvcly- _
Address: c%
Notes:
STEP 1 Measure depth to wager table
to nearest 1/10 ft. ...
Date
month/day/Year
STEP 2 Using Water-Level R arge Zone �•�
and Index Well Map IDcate
site and determine:
OAppropriate index well............... {Y/ 1 "'
l�J Water-level range zone .......................... Q
............. ".
STEP 3 Usingmonthly
report.''Current
Water Resources..Cond tions'
determine current depth to
water level 'for index;,yell
month/year
STEP
4 Using Table of Water- evel
Adjustments '`��Na•��: _ i
for index well (STEP 2A), current depth
to water level for index.well
(STEP 3), �:== •�-..<, -.;�=,.
and.water-level zone (STEP 2B)
determine water-level adjustment .... `u`" '`"
.. ..................................-.......................................... .... �`_
STEP 5 Estimate thw= -� r
dep to high water „rr
by subtracting the water- `
is
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) =4 S-v=a
(,
Figure 13.--Reproducible computation fo-m.
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
I
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
�ECE�VED
Property Address: 85 Bog Road i
Marstons Mills, MA 02648
Owner's Name: Don Blair MAY 1 2 Z
003Owner's Address: 127 Commonwealth Road
TO�NN OF BARSTABLE
Wayland MA 01778 PT,
HEALTH DE
Date of Inspection: April 22, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map: 045
Mailing Address: P.O. Box 49 Parcel: 012
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Nlis
Further Evaluation by the Local Approving Authority
F
Inspector's Signature: Date: April23, 2003
The system inspector shall subr 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 shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/1'5/2000 page 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 BoQ Road
Marstons Mills, MA
Owner: Don Blair
Date of Inspection: April 22, 2003
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:
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:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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:
2
• Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Bog Road
Marston Mills, AM
Owner: Don Blair
Date of Inspection: April 22, 2003
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 310 CMR 15.303(l)(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 salt marsh
2. 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
• Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Bog Road
Marsions Mills, NM
Owner: Don Blair
Date of Inspection: April 22, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (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.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either`yes"or"no"to each of the following:
(nt e following criteria apply to large systems in addition to the criteria above)
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
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 85 BoQ Road
Marstons Mills, MA
Owner: Don Blair
Date of Inspection: April 22, 2003
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:
Yea No
✓ 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(3)(b)].
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 85 Bog Road
Marston Mills, MA
Owner: Don Blair
Date of Inspection: April 22, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 1
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Private well
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never Pumped-per owner
Was system pumped as part of the inspection (yes or no): No
If yrs, volume pumped: 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:
Sep. 11/00-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Pale 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Bog Road
Marston Mills, MA
Owner: Don Blair
Datte of Inspection: April 22, 2003
BUILDING SEWER(locate on site plan)
)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ locate on site plan)
( P )
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no sign of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
I
Page 8 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Bog Road
Marston Mills, MA
Owner: Don Blair
Date of Inspection: April 22, 2003
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
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: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level and clean. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Bog Road
Marstons Mills, MA
Owner: Don Blair
Date of Inspection: April 22, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number: 4 infiltrators- 10'x 30'x 2'-per as built card
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.):
There were no signs of failure from the leach field The bottom to grade was 5.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: None (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.):
9
• Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Bog Road
Marstons Mills, AM
Owner: Don Blair
Date of Inspection: April 22, 2003
Map: 045
Parcel. 012
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 100 feet. Locate where public water supply enters the building.
A B
' lCft +
A a a O
F. $7 3
a 43 89
y
3 6s 90
10
Page i l of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Bog Road
Marston Mills, AM
Owner: Don Blair
Date of Inspection: _April 22, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 15 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record -If checked, date of design plan reviewed:
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: topographic and water contours maps
You must describe how you established the high ground water elevation:
Using the USGS topographic map and the Cape Cod Commission water contours map the maps were showing approximately
15'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
TOWN OF BARNSTABLE
i �OLOCATION SEWAGE # 2,MV7757"
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 160/ e qJ j 6D45,7,- 77 V-0�;,49
SEPTIC TANK CAPACITY &,,I-
LEACHING FACILITY: (type) ".4 (size) 149 X"20 X—I
NO. OF BEDROOMS
RCW
—
) I N1T BUILDER C
I -PERMITDATE: COMPLIANCE DATE:
Separation Distance Between,the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �fiFeet
Private Water Supply Well and Leaching Facility (If any wells exist.
on site or within 200 feet of leaching facility) 14AV 7& Feet
I Edge of Weiland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
V/
/Z
zeiz-
'77
TOWN OF BARNSTABLE
l�U'� 0 �• SEWAGE #
LOCATION l
VILLAGE MAC b^1 /ti11rs ASSESSOR'S MAP & LOT QyS loL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /!ryD��
LEACHING FACILITY: (type)�' /�riA4Q/� .-J (size) /0
NO. OF BEDROOMS 3 R l
BUILDER OR OWNER r
PERMITDATE: COMPLIANCE DATE:
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 leac 'ng facility Feet
Furnished by.r T/�SD lug, �D/�
1 ,
row �
lot
a
A
6 O
3
a 63 99
3 6s 90
�f (06 886
TOWN OF BARNSTABLE
L`OCATIO,N, Ae'? 40�-' SEWAGE #
:VILLAGES�-�� I/ll� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ETT'(
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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
�ly
F
f� C TOWN OF BAFNSTABLE
f.0°.�AT10NCt�CP/� SEWAGE #
V.I,l,AGE, 19:2 P�n� NEVI ASSESSOR'S MAP & LOI ISDI�•CX
y
aNS'eaC °S NAME&PHONE NO,&.f&14�
SEPTIC TANK CAPACITY I
` LEACHING FACU-=: (type) 4 t I k (size) ICE' }�20'k Q �
NO. OF BEDROOMS
BUILDER OR 1WNER 6a.or
PERMITDATE: COMPLIANCE DATE:
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
�{ °
° Q�C
IN
�1
Q
1
60
'< TOWN OF BARNSTABLE °C
L .TION AO ��� SEWAGE #
LfiPJD SZ�
1.AGE /04i1-iS/V05 ZV 1 f/J ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 6,org� j ����`.�'.7 7191
SEPTIC TANK CAPACITY l j�O GgL
LEACHING FACILITY: (type) T1 fl�C�rs��1� (size) /49V'X41
NO.OF BEDROOMS 3
BUILDER OR � d10
PERMITDATE: �/� Bd COMPLIANCE DATE:
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 & Y-
��� I s s
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No.2 J 7 Feer�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zppltration for Migonl bpotem Construction Permit
Application for a Permit to C s t( . )Repair(y)Upgrade( )Abandon( ) M Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
gel,*0J01—/
7 7/
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( �D
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow>IO a' = 316 6 gallons per day. Calculated daily flow ��D gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank O Type of S.A.S. L4 y-
Description of Soil
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 issued by this Bo d of ealth.
Signed Date flel ey
Application Approved by Date —Z'0w
Application Disapproved for the following reasons
Permit No. `. Z-7 Date Issued
0�5 S Oaz, O� z
3 /
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
} i Yes
PUBLIC HEALTH DIVISION - TOWN`OF BARNSTABLE., MASSACHUSETTS
2pprication for Migpooar*p.5tem Construction Permit
Application for a Permit to Construct Repair Y Upgrade( )Abandon( ) /complete S stem ❑Individual Com nents
PP ( ) P ( ) PgY Po
Location Address or Lot No. ` /�® • Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7 �/✓ 3
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( �d
Other Type of Building lee,51WLllee No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow &"* gallons.
Plan Date Number of sheets Revision Date
Title
'Size of Septic Tank /$—O'4 99 Type of S.A.S. y' #/9� �4J✓�Cl��/'Zii l�,pa/ars
Description of Soil
.,Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensurethe 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 issued by this Bo d ofAiealth. — /���
Signed Date
Application Approved by Date V7 7-ew
Application Disapproved for the following reasons
Permit No. S Z Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS OY 57 ^1�)/ .eW Z
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance ✓
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired( )Upgraded( )
Abandoned( )by % C `
at 7 X09 �0"5�`d��` has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. "-S-Z dated 7 ' ?i0r .
Installer Designer Al
The issuance of this permits al not be construed as a guarantee that the sy tern 11 fun ion s esigne�
Date _ Inspector �� PY
�J
—ZD?y,r-O ---------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
R Z PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS
%0f6po0al *pgtem Construction Permit
Permission is hereby granted to aironstruct )Rep ✓)Upgrade( )Abandon( )
System located at 6 7 Oy /' 9I$TeA57 4////5
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Constructio must be completed within three years of the date of this ermit.
` `Date: Approved by ��•
NOTICE: This Form Is To Be Used For the Repair Of Failed
Se tic Systems. Only. -
CERTIFICATION OF SHITCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS),
L -&kl'7-7-, A®/'&Wh hereby certify that the application for disposal works
PP p
construction permit signed by me dated /6l®® concernin.2 the
property located atS meets all of the
following criteria:.
4e failed system is connected to,a residential dwellingonly. There are n o commercial or business
uses associated with the dwelling.
i ae soil is classified as CLASS I and the oe coiation rate is less than or:aual :o minutes oer inch.
v "fie.-e are no wetlands within 100 feet of t- a or000sed septic system
Y There are no private wells within 1:0 feet of the proposed septic s✓sem
y i here is no increase in flow and/or change in use oroposea
There are no variances.requested or needed.
JThe bottom of the proposed leaching facility will not be located less than five feet above the
mxcimum adjusted groundwater table elevation..(Adjust the groundwater table.using the rnmptor
method when applicable]
Y If-the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
P .
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please.complete the following:
A) Top of Ground Surface Elevation(using GIS information) ` v
B) G.W.Elevation q Z +the MAX.High G.W. Adjustment. 7 = L1 d
DIFFERENCE BETWEEN A and B
SIGNED: �' DATE:
(Sketch proposed plan of system on back].
4F ham fo+aw.am
•,. t
kl,Z1160
K
$ 30 .00
No.I.,3.SDo Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOARD HEALTH
e
TTC�
Barnstable Conservation Depart
WN OF BA,RNSTABLE
4$f
Application is hereby made for a Permit to Construct ( ) or Itepair (XX) an Individual Sewage Disposal
System at:
5 Bog Road Marston_s Mills
.............. ----••..............._............ .-----•-----•---•---•-----••-------------- ....__.................................
Petrovits Location•:\ddress or Lot No.
......................_.......................................................................... .................................................................................................
O�,ncr W J .P.Macomber Jr. Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling X No. of Bedrooms-------------3-----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons----------.................. Showers ( ) — Cafeteria ( )
at Other 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 ( )
0.4 Percolation Test Results Performed by..........................................................................••-•-• Date...................................................................
Test Pit No. 1................minutes er 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........................
W •--•-•-••-•------•-----•----•----•••--•---••----•-•-•-•------•----...-•--•--------------------------.........................................................
0 Description of Soil...............Sand & Gravel ---------•--------------------•--------------...-----•--------................
•-• .....------
V
W ...•••-•-••......................••-••--•. . . . -•-..._....--•••-............----•----......•-- -••-••-•-•--------•-------...---••-------•--•--•----•------•••-••-•-•..._...........-----..._.....
U Nature of Repairs or Alterations—Answer when a plicable._._....1-10 0 0 gallon tank 1_distribution
p - - -
box 1-10 0 gallon leaching pit: Omit existing cesspool .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliapce hasbeqp issued by the oa of health.
Signed . . . ... ... ............................... ......9/8/9 3.....:......
Dare
Application Approved By ............ � ..................... --------.---------------- ........7. �. ....
Date
Application Disapproved for the following reasons: .......................................
...................... . ................................................. -- . ......................... ... . ................................................. ... . ................................
a- Date
PermitNo. ...........1..---? ..a..2?------- -----..... Issued ............................................................ . .
Date
�.
�+faw"•v-i+r-w��--�..t.�_y,�,..,.a"y,.,�'�.^i`S:✓�•T.-,ti,-�,y�^..`_"..'�'vV' vti� ,-_...-��.:�.wY^�� 4�..-..�•: �—�w —.,_. _ ___�— 7•- _ �
� t -
$ 30.00
No...`...: - FIz$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
h�
Appliratinn for Diri.pnittl Works Tomitrnrtion Famit
40 Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal
System at:
Bo Road Marstons..............g ...---.............. ----- -------- -•---Mills--•..... -.........
Petrovits Location-Address or Lot No.
......................_.......................................................................... ------------•-------••--------...----••--••---•-----------•--••--...........---------...........--
W J.P.Macomber Jr. Owner Address
Installer Address
UType of Building t Size Lot............................Sq. feet
.-t Dwelling No. of Bedrooms..............3---_-.-_-._---_--____--.--.-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-__-_----_---_-_._ -rotal Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. I................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........................
9 ....-------•--•--------------••••--•-•._....__......-------•-------••-----------.........._.._...............................................................
0 Description of Soil...............Sand & Gravel
....
V .----------------------•-------------•-•--••--•---------------•----- •-•---..-•-• ----•--------• -----_.....------------••••..... .... ...................- .........
W
U Nature of Repairs or Alterations—Answer when applicable_......1-10 0 0 ga 11 on t a nk 1-d i s t r i but i on
p ..............................................................
box 1-10 0 gallon leaching pit. Omit existing cesspool.
-•-------------------------------------------------------------------;----.......----•------------------_._...------------------------....---•------------------•----------•--•-•--•......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has ee.n issued by2theoar of health.
Signed ........-. f 9/8/93
...F....................... - ...
Application Approved By ............ v - --.�— a� ...... ........- - - ..: e...�..�.. _3
Application Disapproved for the following reasons: ................ .................................................... ................................... b
................................................................................... .......... ........................................................................................................... -------------
*....................:.....
PermitNo. .........../...??.-..: ,. ?--------------------- Issued -------------......................................................�.
Dace
THE COMMONWEALTH OF MASSACHUSETTS
1
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fer#tf rate of C�omplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX )
J.P.Macomber' Jr.
by ----------- - ------------------------------------------------_._..... .. .._........ .................. ..... .. .. ...............................-- ........................-- .......................
15 Bog Road Marstons Mills
at ........ ... ......... ... .................. ......----------- ------------------....----------------------------------.-.
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...-. ..... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ .. .._................_.................._..........._............ .............. Inspector --------------------------------.._._:..................................................
----+'---—-----®-----" u —THE COMMONWEALTH OF MASSACHUSETTS ——————
BOARD OF HEALTH
�n TOWN OF BARNSTABLE $ 30.00
No.... �I FEE........................
his 1Qo�t1 r� �>an�tr uan �Prmtt
�
Permission is hereby granted P. acomber J r. .................
to Constr ct (( ) or Repair (XX) an Individual Sewage Disposal System
lu5 Bo Road Marstons Mills
atNo. -------- •---------•...---- ---• ----. ------
Street
as shown on the application for Disposal Works Construction Per No. x.,1.96 Dated.._. _. !Y.`.....................
r -'l- a
-------- --------------.........................
g ( / Board of Health
DATE..-- -- - � ............... ........... ,_...
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS