HomeMy WebLinkAbout0022 BOSUN'S WAY - Health 22 Bosun"s 'flay
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... 22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
r" Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 61 IS ae Li
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites Path.
Company
Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes 0
s6,,9����%
?' MICHAEL �yN'
3. ❑ Needs Further Evaluation by the Local Approving Authority = m a
_o. SEARS -�
* No.SI14430 y
4. El Fails
INS?
4-1-21
Inspector's Sig ure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bosun's Way.
V�
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in working order
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Q Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7;26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bosuns Way.
u�
Property Address
Kathleen Thonet
Owner Owner's Name
requir at for
Marstons Mills Ma. 02648 4-1-21
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has,a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 10 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
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u� 22 Bosun s Way.
Property Address
Kathleen Thonet
k Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
,
< Commonwealth of Massachusetts
Title 5 Official Inspection Form
'' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bosun's Way.
V�
Property Address
Kathleen Tho.net
Owner Owner's Name
information is
required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number o-bedrooms(design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2019- 21000 gal
g ( y g (gpd)) 2020- 21000 gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
cAN, Commonwealth of Massachusetts
a Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c !% 22 Bosun's Way.
u�
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Feb, 2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7.26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bosun's Way.
V�
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
4-15-04 #2004-174 New SAS
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7.126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
:, ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............ !% 22 Bosun's Way.
u—
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle 29„
Scum thickness 0
8,1 �
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Sludge judge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 gal tank with baffle in and out tee in place, inlet cover 2" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
III' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
informatics is required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions: ,
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
i
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ale Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
it
D Box is 16x16 with 2 outlet pipes, Box at 32" below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is Marstons Mills Ma. 02648 4-1-21
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
' If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is
required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 2- 500 dry wells, chambers are clean and dry with no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 Bosun's Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 4-1-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary
g p y o untary Assessments
!% 22 Bosun's Way. —_ `--- -
Property Address
Kathleen Thonet
Owner Owner's Name
information is Marstons Mills Ma. 02648 4-1-21
required for every _
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
i� 9,.,¢,
.� W.'P '
gr �<
0 0
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 116 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 Bosuns Way.
Property Address
Kathleen Thonet
Owner Owner's Name
information is
required for every Marstons Mills Ma. 02648 4-1-21
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 144"
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1978
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:-
El Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
No ground water per plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 Bosun's Way. _
Property Address
Kathleen Thonet
Owner Owner's Name
information is Marstons Mills Ma. 02648 4-1-21
required for every — ._
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
G re,de
go i �:v,off' SAS
AvO G,-vra wj�u
t5insp.doc•rev.7/2e/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
I
TOWN OF BARNSTABLE ��
LOGArI0N o?A I6a'5®yl5 !�J4;2 SEWAGE #
VII.LAGE /�'I /�Io/�S ASSESSOR'S MAP & LOT Oq ''II
INSTALLER'S NAME&PHONE NO. 7TJ/l7'i 44111-41 ie1v
SEPTIC TANK CAPACITY /.,00a GAG
LEACHING FACILITY: (type) 32YO ei e4w 0,,J (size) /�•t X.?s" ><.7'
NO.OF BEDROOMS 3
B UILDER OR< WNE T1 ray.
y
PERMITDATE: i� D"y 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
Feet
on site or within 200 feet of leaching facility)
/} t
Edge of Wetland and Leaching Facility(If any wetlands exist s
within 300 feet of leaching facility) Feet
Furnished by 194wo 9fol" Li rv++rrN�
ly-I'A2
�. ya,
V3 30 r _ XI
c `
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1Z
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprication for Mi5pool *pgtem Con!5truction Permit
Application for a Permit to Construct( . )Repair(✓)Upgrade( )Abandon( ) ❑Complete System LrIndividual Components
Location Address or Lot No. we/� Owner's Name,Address and Tel.No.
li ✓ Vv�G
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. l`/ �7 / Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms�a Lot Size sq.ft. Garbage Grinder( )
Other Type of Building /Ke�lYe4t4 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ll o gallons per day. Calculated daily flow �� it e� gallons.
Plan Date 3Z Number of sheets / Revision Date
Title Cl`1 Z 4Oe25el&�5 a/4i sz
Size of Septic Tank /6102'-P e,-t jV4-/ems Type of S.A.S.
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 is B and He l
Signed Date
Application Approved by t Date qZA U
Application Disapproved for We following reasons
Permit No. L Date Issued
4
No. �oolj_ 1-7 L/ Fee
THE COMMONWEALTH OF MASSACJ-IU SETTS Entered in computer:
"Of, I Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Miqog;al *p!6t1__ Con.5truction Permit
Application for a Permit to Construct Repair V/)Upgrade Abandon El Complete System Ltl'Individual Components
Location Address or Lot No. 7,0 I al)l 0 wner's Name Address d Tel.No.
Assessor's Map/Parcel ✓ " an
011e
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
f 2&)/,��
-7
Type of Building:
Dwelling No.of Bedrooms J� Lot Size- 3ql2l�r sq.ft. Garbage Grinder
Other Type of Building R&_`2)d�1eeeNo. of Persons Showers Cafeteria(
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date 5 l y Numb of sheets Revision Date
Title P 7 , 7 e - Z
Size of Septic Tank Type of S.A.S.
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 B aid Heal&
Signed Date
/�s(r��
Application Approved by _L2,A i - Date
Application Disapproved for K following reasons
Permit No. Dvvq- 1 7 q Date Issued
——————————————————————————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the/On s to Sewa Di posal System Constructed Repaired Upgraded'ge
Abandoned by _is
at 7- 2 ;; ��/3has been constructed i /accordance
/y with the provisions of Title 5 and the for Disposal System Construction Permit No. POO'/—/ dated UV
Installer I Designer
,)
The issuance this I/ permit shall not be construed as a guarantee that the �N;tern 'll function as d d
Date 1i O'l , Inspector AV
————————————————---—
No. 0 0 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi!5po!9al *p5tem Con5truction Permit
Permission is hereby granted to Construct Re, air �)Upgrade Abandon
System located at &4
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:Construictionfinust be completed within three years of the date of this-permi
Date: 0410 V Approved by c1f 1"", Pr
V
TOW
N OF BARN STABLE TABLE
y/7
q SEWAGE # y
LOCATION rXoZ �a e 4 o,
VILLAGE I'yJ i9 z/J ASSESSOR'S MAP & LOT
�)
INSTALLER'S NAME&PHONE.NO. �� r
SEPTIC TANK CAPACITY' ano
•• �U Ca( lei bosh �. (size)
LEACHING FACILITY: (type)
` NO.OF BEDROOMS 3 `
BUILDER O WNE T 011!
PERMTTDA 2-r//t.—/ COMPLLkNCE TE: DATE:
Separation Distance Between.the: 1--,A Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist
/j-� t Feet
on site or within 200 feet of leaching facility),.
Edge,of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
O A1.a-__2
r
r + 41-
COMMONWEALTH OF MASSACHUSETTSs
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
L Y:
DEPARTMENT OF ENVIRONMENTAL PROTECTION �
r
�3
h
t
TITLE 5t
R
OFF
ICIAL INSPECT
ION F VOLUNTARY ASSESSMENTS FORM—NOT O z. . .
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM '
PART A
CERTIFICATION x
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA,02648
>�
Owner's Name: BEN GUTHRIE y
Owner's Address: 22 BOSUNS WAY MARSTONS MILLS,MA.02648
r
Date of
Inspection: 12/12/01
Name of Inspector: (P print)
lease rint JOHN GRACI �ECEIVED
i
nC
Company Name: SEPTIC INSPECTIONS �
Mailing Address: ,�Pj.O.BOX 2119 TEATICKET,MA.02536 DEC 2 0 2001 F k ;.
Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE r
HEALTH DEPT.
t �
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system.at 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`naintenance of on site sewage disposal systems.I am a DEP approved systems
inspector pursuant to Section 15.M0 of Title 5(310 CMR 15.000).`jhe;system:,
S
X Passes _
_ Conditionally P sses
Needs Furt valuation by the Local Approving Authority
_ Fails `
Inspector's Signature: Date: 12/12/01
f c
i The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)wtthm ��N,
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 ,k
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be.
t
i sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. n$. 41
i Notes and Comments
SYSTEM PASSES TITLE V 1NSP4ECTIONRECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. y
****This report only describes conditions at the time of inspection and under the conditions of u This
at that time,
inspection does not address how the system will perform in the future under the same or different conditions of use. V.
. I3
tr:
Title 5 Incnr.rtion Form A/]50MO i
Page 2 of I 1 _
r^ .
• CS
OFFICIAL INSPECTION FORM—NOT FOR`VOLUNTARY ASSESSMENTS
( kM
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A �
CERTIFICATION(continued) ,
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648
Owner: BEN GUTHRIE '' Y
Date of Inspection: 12/12/01 �
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
t an of the failure criteria described in 310 CMR 15.303 or in 310
n found an information which indicates that :.-,i. .,,,
i X I have of y Y
'� 4
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. `��
4 * ,_
B. System Conditionally Passes:
_ One or more system components as'described in the"Conditional Pass"section need to be replaced or repaired.The system, 3r`
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 '�?A
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits z
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
j
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 xft `
that the tank is less than 20 years old is available.
ND explain: n/aZ4�
n/a 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 ;� ;c
Health): �!
_ broken pipe(s)are replaced '
_ obstruction is removed _{ v
4A.
_ distribution box is leveled or replaced ._
s+"
ND explain: n/a
n/a The system required pumping`niore than 4 times a year due to broken or obstructed pipe(s).The system will pass x. s�
inspection if(with approval of the Boar.d of Health):
_broken pipe(s)are replacedF
_obstruction is removed `
i.F
ND explain: n/a
,
04.
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A4.
CERTIFICATION(continued)
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648
Owner: BEN GUTHRIE
Date of Inspection: 12/12/01 =.
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 4
protect public health,safety or the environment. afr:t
1. 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
salt marsh
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a is
.a�
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that they
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 '
t�
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 4
supply well". Method used to determine distance n/a `
"This system asses if the welliwater Analysis,performed at a DEP certified laboratory,for coliform bacteria and -.
Y P Y ,P rY� . ��• '
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: Fri
n/a ,
x
v
I
Page 4 of I 1
x3
9
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTSY`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM «.
PART A �.
CERTIFICATION(continued)
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648 ,
Owner: BEN GUTHRIEs
Date of Inspection: 12/12/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections: _ ;
Yes No
X Backup of sewage into facility or stem component due to overloaded or clogged SAS or cesspool
- P g tY Y P gg p
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged '
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ��
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow <.; -..
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times :
9..�pk
pumped nLa. ^
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation. �f
X Any portion of cesspool'or privy is within 100 feet of a surface water supply or tributary to a surface water supply. �{
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well. r _
_ X 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 asses if the well water analysis,performed at a DEP
P q Y Y I Y P Y +P N•� �[r
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is freer `
from pollution from that�facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or ; h
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 � a:
y:
necessary to correct the failure. � r�
ACV 4-
E. Large Systems: . 4 � r.
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) ''a
I. ,
yes no
_ X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply E =�
' 'nit'ro en sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
_ X the system is located in a ( a.
Y g _
Zone 11 of a public water°supply well
If you have answered"yes"'fo any question in Section E the system is considered a significant threat,or answeredt'sax ';
"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 sltall upgrade the system In accordance with 310 CMR 15.304;Thu System owll®r
should contact the appropriate regional office of the Department. '
g
g;����.
r
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS °' '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B x 't''Fyfl !y
CHECKLIST
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648
Owner: BEN GUTHRIE rkkt
Date of Inspection: 12/12/01
r'�A
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health ,*, .
X Were any of the system components pumped out in the previous two weeks? � ;
X _ Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) '
1
a
X _ Was the facility or dwelling inspected for signs of sewage backup? ,
X _ Was the site inspected for signs of break out? ' .
X _ Were all system components,excluding the SAS, located on site? M
X _ 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? � '
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance �z
of subsurface sewage disposal systems? ;
The size and location of the Soil Absorption System(SAS)on the site has been determined based on: A
Yes no
X _ Existing information. For'example,a plan at the Board of Health.
X _ Determined in the field if an of the failure criteria related to Part C is at issue approximation of distance is .. ,�
unacceptable)[310 CMR 15.302(3)(b)] ,
1T
��
Page 6 of 11
t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ;�x,�
SYSTEM INFORMATION
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648 h`
Owner: BEN GUTHRIE F'
Date of Inspection: 12/12/01
FLOW CONDITIONS , ,
RESIDENTIAL s h i41�i#ii tk.
Number of bedrooms(design): 3 Number of bedrooms(actual): 3 `
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:3 y `
E�}
Does residence have a garbage grinder(yes or no):NO Al
Is laundry on a separate sewage system(yes or no): NO [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)): n/a
Sump pump(yes or no): NO .. .,
Last date of occupancy: n/a at
COMMERCIAL/INDUSTRIAL ,r
Type of establishment: n/a
Design flow(based on 310 CMR;15.203): n/agpd `.
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
f k 'w
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to`the Title 5 system(yes or no): NO
Water meter readings, if available: n/a � .ai
Last date of occupancy/use: n/a x
OTHER(describe): n/a '
GENERAL INFORMATION
Pumping Records ,?y
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a � :
Reason for pumping: n/a ,
z�
TYPE OF SYSTEM r ;
X Septic tank,distribution box,soil absorption system : � .
_Single cesspool `�r
_Overflow cesspool r Z4
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
A,�
_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): n/a
,
Approximate age of all components,date installed(if known)and source,of information:
NEW FIELD IN 98
Were sewage odors detected when arriving at the site(yes or no): NO
gq
Eba
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `a
PART C '.x.
SYSTEM INFORMATION(continued)
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648 ; x '
Owner: BEN GUTHRIE .
Date of Inspection: 12/12/01
C x�a
BUILDING SEWER(locate on site plan) ,
Depth below grade: 2" `�:
Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC t
Distance from private water supply well or suction line: n/a t
Comments(on condition of joints,venting,evidence of leakage,etc.): :'z
WELL WATER *
T
SEPTIC TANK: X(locate on site plan)
h
Depth below grade: 0" ;
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a t.
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) 1
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"�"
Sludge depth: n/a `
Distance from top of sludge to bottom of outlet tee or baffle: n/a :�
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a :.
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
t. .,.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a „.
Material of construction: concrete metal fiberglass_polyethylene_other(explain): n/a �a
Kam, ,
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a '=
Distance from bottom of scum to bottom of outlet tee or baffle: n/a '
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, li liquid levels as related
q
to outlet invert,evidence of leakage,etc.): °`~
n/a :,
2_
t
F
f '
Page 8ofII
s a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648 .'
Owner: BEN GUTHRIE
Date of Inspection: 12/12/01
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): n/a
Dimensions: n/a
Capacity: n/a gallons '_
Design Flow: n/a gallons/day 0 '
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a ,
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present.must be opened)(locate on site plan) IT
h
: ,
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.): �� r
BOX IS STRUCTURALLY SOUND. ° ` x
PUMP CHAMBER:_(locate on site plan) ` r "`
�I
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): -«
n/a
;a
7 4
} t
a
r
"- �1 '.
a�a
Page 9 of 11
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM *¢: "
PART C
SYSTEM INFORMATION(continued)
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648
Owner: BEN GUTHRIE `
Date of Inspection: 12/12/01 *`r
E
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a ,.
S Y
Type a
1000 GAL 6'X 6' leaching pits, number: 1 '`
RECHARGERS leaching chambers, number: 3 £ ` `
n/a leaching galleries, number: n/a
leaching trenches, number, length: n/a
0 leaching fields, number: n/a ,
n/aoverflow cesspool, number: n/a
n/a •1 „innovative/alternative system
T pe/name of technology: "
Y n/a ;;
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): �`
LEACH PIT AND LEACHING FIELDS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. DID NOT EXPOSE,NO INSPECTION COVER RAISED.BOTTOM IS AT 6' ON THE FIELD AND
�4
BOTTOM IS AT 8' ON THE LEACH PIT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
-24
Depth—top of liquid to inlet invert: n/a <`
Depth of solids layer: n/a ' -'
Depth of scum layer: n/a
Dimensions of cesspool: n/a U= '
Materials of construction: n/a
Indicatilon of groundwater inflow(yes or no): NO
Comments note condition of soil,signs of hydraulic failure, level of ponding,condition of ve etation etc.):
( g y p g g .w;.
n/a
PRIVY: (locate on site plan) R:
Materials of construction: n/a �r
Dimensions: n/a r,
Depth of solids: n/a ,K
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a �
t .Y:
Ifn;�
4
f '
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS p* ;r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
k.
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648 R "
Owner: BEN GUTHRIE
Date of Inspection: 12/12/01 1?:
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.
4� 1
NO-
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Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -,4
PART C
SYSTEM INFORMATION(continued) A'
Property Address: 22 BOSUNS WAY MARSTONS MILLS,MA 02648
Owner: BEN GUTHRIE 5
Date of Inspection: 12/12/01
SITE EXAM
_Slope
_Surface water a
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
Y g P g P
YES Observed site(abutting property/observation hole within 150 feet of SAS) °
NO Checked with local Board of Health-explain: n/a
installers- attach documentation "
NO Checked with local excavators, ( ) ':=�•
YES Accessed USGS database-explain: n/a '.
r elevation: ti±`
You must describe how you established the high round Ovate •.� :;
Y g g
GROUNDWATER DETERMINED FROM AUGER-NO WATER 12'
Y
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wi
t
F$t
L
TOWN OF BARNSTABLE
LOCATION 00 a s SEWAGE #
VILLAGE /h A t. c'L iQ 1�511 I S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Z�e ji►A 2< 2 (size)
NO:OF BEDROOMS .pJ
l
BUILDER OR OWNER
PERMITDATE: -' ' _COMPLIANCE:DATE: �=; f
Separation Distance Between the:
Maamum Adjusted Groundwater Table and 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
: i
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- TOWN OF BARNSTABLE ,�//
LOCATION t-2 C_S S SEWAGE # L il 13
ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. d!C,4 9 1-- E'.-
SEPTIC TANK CAPACITY, lenn A 4A
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER,:
PERMITDATE: .' g - _COMPLIANCE DATE: '?a,.
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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No. 7 9�. , . Fee$ 50 .0 0
THE COMMONWEALTH OF MA SACHUSETTS Entered in computer:
Yes
PUBLIC`HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipphiation for Migpogal *pgtem Congtruction permit
Application for a Permit to Construct( )Repair XX)Upgrade( )Abandon( ) [l Complete System E]Individual Components
Location Address or Lot No.2 2 Bosuns Way Owner's Name,Address and Tel.No.
Marstons Mills,Mass. 02648 Lynn Lindsey 02655
Assessor's Map/Parcel
6 —11 131 West Bay Road Osterville,Mass
Installer's Name,Address,and Tel.No. 510 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5 3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms I Lot Size sq. ft. Garbage Grinder( )
Other Type of Building Res No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 X 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.F.x i .t-i n g h 'x s ' n l t-
Description of Soil ylm sand d .ova r s e s a n d
Nature of Repairs or Alterations(Answer when applicable) —3 3 0 t 1 _ rP .h a rCjP r s
packed in 3 ' of 1 '-z" stone with a 3/8" stone cap.
Date last inspected: 3/3/9 8
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 issue by this B d f He lth.
Signed Date 3/3/9 8
Application Approved by Date
Application Disapproved for the following reasons
Permit No. f Date Issued
i ———————————————————————————————————————
n ♦r ,r.. - .. /. e .+.«,.ate...... ..(G-.., w .-.. gyp. ,...i .. ,_ �, �,
No
�j,FA
+ ,�,7 a �� - _ Fee 5000/
q THE COMMONWEALTH OF MA SACHUSETTS Entered in computer:
Yes
4 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Migaar *pztem Cowaruction Permit
Application for a Permit to Construct( )Repair 1!(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.22 Bosuns Way Owner's Name,Address and Tel.No. 02655
Marstons Mills,Mass. 02648 Lynn Lindsey
Assessor's Map/Parcel A --119 131 West Bay Road Osterville,Mass
Installer's Name,Address,and Tel.No. 50 8—7 7 5—3 3 3 8 Desi ner's Name,Address and Tel.Igo. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.�.Macomber & Son Inc.
Box 66 Centerville;Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Res No.of Persons Showers( ) Cafeteria( )
{ Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 X 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank EV{ S t; „g 1800- & bn --Type of S.A."S.Existing 6 'x8'6bit.
Description of Soil Medium Rand to coarse san&_ . �
+' f
Nature of Repairs or Alterations(Answer when applicable) 3-330 Cultec rechaft@Brs
packed in 3 ' of 1j" stone with a 3/8" stone caps
L
Date last inspected: 3/3/9 8
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 issue by this B d f He lth.
Signed _ Date 3/3/9 8
Application Approved by Date Jam'
Application Disapproved for the following reasons
Permit No s' Date Issued 4.7
� p
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (XX) Upgraded( )
Abandoned( )by J.P.Macomber & Son Inc.
at 22 Bosuns Way Marstons Mills,Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. , dated Y,- 6!�'"—"0- .
Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Ince.
The issuance of thij�ermit.shall of be construed as a guarantee that the syste will function as designed.
Date `~ tInspector .�
-- -------------- ------- --
No. f '' Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
'Wi0pozar *pgtem Comaruction Permit
Permission is hereby granted to Construct( )Repair�X)Upgrade( )Abandon( )
Systemlocatedat 22 Bosuns Way Marstons M111s,Mass
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:Construction• mustbe completed within three years of the date of thi )prmit.
Date: ' p' roved bY A
1. PP _
�j 10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, Joseph P.Macomber jr. , hereby certify that the application for disposal works
construction permit signed by me dated. 3/3/9 8 , concerning the
property located at 22 Bosuns way Marstons mills. meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will n2l be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 7
B)Observed Groundwater Table Elevation(according to Health Division well map) 3 5 ,
SIGNED
DATE:
LICE N SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Y7
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:heath 1 folder:cert
n
1
C
r
r' i2ej 7-6
7
L0 .,,AT, � PERMIT N0.
VILLA'SE
INST 11 R'S NAME & ADDRESS
UI-LD RDo R
DATE ER MIT ISSUED +�
DATE : COMPLIANCE . ISSUED , : 7
e J
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!
No ��1� FEE 0...1::�..�
. '
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA.LT
:. �.P........OF......e4,J. Y?7..��..T cc-----.-1.. ..........................
ApplirFatiun for lliipuual Works Tunitratriiun Prratit
Application is hereby made for a Permit to Construct (?0 or Repair ( } an Individual Sewage Disposal
System at: y
1/_X4ZV Z 0.-1...../ 41 V
IAt
Sh
... ...................•.......... .--.............-•••••......•---•-••. /
J -- Ow er --•-•....................•----•.Address � l[.�
........�.. ... o...... ... ................ ..........---.........••.............----'-•-
Ins r Address
Type of Building Size Lot _. . .' ...Sq. feet
V Dwelling—No. of Bedrooms.........�.............................Expansion Attic Garbage Grinder VV)0
Other—T e of Building No. of persons............................ Showers — Cafeteria
aOther fi es -------------------------------------------------------_--------------------------------------•----------------••-------••------------------------
d /. ....._gallons per person-per d4y. Total dailyflow.......
W Design. Flow-------------------•-•--•--- - g P P a Ol�-------------------•--melons.
WSeptic Tank—Liquid capacity/00Q.gallons Length__-i ..- Width...6........ Diameter................ Depth.___.........
x Disposal Trench—No..................... Width............_..._.. Total Length...._._..__.6._... Total leaching area....................sq. ft.
Seepage Pit No.......�........... Diameter.....®............. Depth below inlet..... Total leaching area..2�..V....sq. ft.
Z Other Distribution box (� ) Dosing t k
~' Percolation Test Results Performed by. � ?.�.s ..-��'..........:............. Date_......." �./_..7 _e,...
aTest Pit No. 1....�------minutes per inch Depth of Test Pit.................... Depth to ground water.._ ...
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ............ 8.._.....
O Description of Soil----•-•-----• �±..d c�wit 9�E' - -- - - - - -
x ./
W ------------------'--.......------------•--•-----•---------'---------------------------...•---'-------------•-----------------'-----•-----------•-----•--•--•----------------•--•-------•-•----•........
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi ILE 5 of the State Sanitary Code The undersign agrees not to place the system in
operation until a Certificate of Compliance has.been issue by the bo d of It
Signe . -•.... .............................................. ----••......................•••-
??at,e
Application Approved BY . .• • --- --- •--.._.._ •. --•__-• -- . •. •-•--•-•-....... •-• ®l..Date '
Application Disapproved for the following reasons:...............................................................................................................
---------------------------•-------...........--•--------......--•--•-----•------•--------.............--•---•-•....-••-•-•-•----------•••--------•--•-•--'•'------•---•-------•-----•--------•--------
Date
Permit No......................................................... �.� Issued. _". _K(F�.................
Date
f
No....... ...� .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA1_T /
rD w h........oF.......
� .Y.h...� .T ---/--e..........................
,� �irtttion for Dispas al Works Tonitrnrtion Vamit
t Application is hereby made for�a,Permit to Construct,(X) or Repair ( ) an Individual Sewage Disposal
Syst at:
as u,�� Q .. ..�.Q.t .h�_.. ...---
....... ......._... .._............. ........
pqpLoc • Ad ss r Lot No.Addressa •-•-•.............................. ..•----•••••......----........•••• -•--•............._...........--•............Address ••//Type of Buing Size Lot.> 7-Z.L....Sq. feet
Dwelling-No. of Bedrooms.,,",..... Attic Garbage Grinder (� p
aOther—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( )
d -
Other es -----•---------------------`-------------------•---•---.....------------------------•---...--------•--..__......------------------------------------...
W Design Flow......... ....1d......gallon's per person �r dy. Total daily flow.......L
............. ...________________.___gallon s.
WSeptic Tank—Liquid capacity/000-gallons Length_r .6.... Width... .....___ Diameter................ Depth....
Disposal Trench—No. .................... Width.................... Tofal,�Length.................... Total leaching area.................... ft.
Seepage Pit No......._�........... Diameter.....lJ.....:....... Depth below inlet................ Total leaching area..o�.9.�...sq. ft.
Z Other Distribution box (� ) Dosing.t nk ('
n
Percolation Test Results•�� Performed by... .4. �??. -�' - . ............................... Date.....
Test Pit No. 1...Q?.......minutes per inch Depth of Test Pit____________________ Depth to ground water...A/i....t___�__.W
(i Test Pit No. 2................minutes per inch Depth.-of Test Pit.................... Depth to ground water........................
........... fO Description of Soil---------------------- a
........ �/
.. _________________ ________________ _____________________________________________________________________________________ ______„ .__U
W ............................. ............................................................................................•-----.........................._.........._..................................
V Nature of Repairs or Alterations—Answer when applicable...............................:........... ...................................................
t
•----•--•----------------------------------------••----•--...-----•--•--•-----------.....-----------------......------......----------------•---------•-------------------------•-------•••---.....----
Agreement:
The undersigned agrees.to`install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITILE 5 of the State Sanitary Code The undersign u_rther agrees not to place the system in
operation until a Certificate of Compliance has been issue by the bo d of lth.
Signe ..... ..
rz, i Date
Application Approved By`— _-- ..+ . ------- d � ............... ...
Date
Application Disapproved for the following reasons-------................... •-•-------.-----••-••--•--------....----•-----•-•--...............---............._
;; Date
Permit No............................ .. _, Issued.__._-
•-- --------------------• P.. -�Zr ---------.._.._..
Date
—-THE COMMONWEALTH OF MASSACHUSETTS
- BOARD OF H.EAL.�T
"... ;�✓f/..:�.O F.. .................. .... �..._..............
,%rrtifiratr of T ut I na
THI 1 0 F T at,the I ?vidual Sewage Disposal System constructed ( ) or Repaired ( )
b - ...............
........ ..... . ... ...--_---. . ....... ...................
..,f ��� !: .. .. Ins - '�! %` ,.......
has been installed in accordance wit the provisions of TITLE 5 of The State Sani ry Code as described in the
application for Disposal Works Construction Permit No......................................... dated------i...._.__......_..-..___................
11
THE ISSUANCE OF THIS CERTIFICATE' SHALL NOT BE CONSTRUE® M A GUARANTEE THAT THE
SYSTEM WILL UNCTION SATISFACTORY.
:ham/�. _
DATE................ ... : l�; _..-V..-----...........•---...._. Inspector... ..........
t
THE COMMONWEALTH OF MASSACHUSETTS'
BOARD jHEALTH•
Dispos orkon #rnr#uan lerntit
Permisriereby granted.=.. ---_. . ---.-��... ....--•.....................................•-----......... .
...to ConstrucRepair ( ) an Individual S .w e D. posal Sy
..
Street
as shown on the application for Disposal Works Construc on Permit No........ ........ D ted./_".. """ ............
...........................•- ..
Board of ealth
DATE.......................................................=.......................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
J
No.-------------------- Fee--l'---- O'er-----------�----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applicat ion-*rVell Con5truct ion Permit
Applicationds hereby made for a permit to Construct ( ), Alter ( ), or Repair ('")an individual Well at:
DD------------ - -------------------------- -----------------------------------------------------------------------------------
/ocation —' dd. Assessors Map and Parcel `
Owner Address
-A A :_S_c e ll - ------------------------- P v_._!��x a -^'`-—s /z -------'°--=`------ -----------
------
Installer — Driller .Address
.Type of Building
Dwelling---�8'..t`s_ -
--------------------------------------------------
Other - Type of Building------------------------------------ No. of Persons----------------------------------------------------
Typeof Well- --- -- - ------------------------------------------- Capacity-------------------------------------------------------------------
Purpose of Well---p0-'�"_es
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Ceertificateof Compliance has beenn i ued by the Board of Health.
Signed ----- - --
date
Application Approved B - - --------- - = -—
date
Application Disapproved for the following reasons:--- -----------------------
----------
------------
------
------
------------
------------ -- - —--- i-------—-------------------------------------------------------------------------------------------------------------
�� 1� date
Permit No. — ----
® -------------- Issued --- � /`=------ - -----------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired
11L-j--------------------------------------------------------------------------------------------------
--
Installer
(� ra
at--------�'� 'JoS_cr 3 w �------ M urS rG>=5----�-f-/-ll----------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit Nk1---R- Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------- ------- —-- ---- -- Inspector----------------------------------------------------------------------------
BOARD OF HEALTH
'r TOWN,-: -F-- BAR.N.STABLE
Ve[r Con$truct ion Vermit
No. -'-=�f--M1—" Fee----- ------�
Permission is hereby granted f-----------------------------------------------------------------------
'to Construct ( ), Alter ( ), or Repair ( !-Ian Individual Well at:
No. ---— -------------- --------------------------------------- ----------------------------------------------------------
Street
as shown on the a licat'on for a Well Construction Permit
/ ,...
No. - — �_—` ----------—-------------- Dated- — ---l-
�---- -----------------
_r`
_5
Board of Health �...
DATE--
Poe r�
... No. - -------------
-�' Fee-
1 BOARQQF_HEALTH
OWN OF BA NBTABLE
g
Zip [uationArlVef[ C q�tratt nPermit
2•��2 oC� C pair ("')an individual Well at:
Application 's hereby made f r a permit to nsfr t � ), Alter ( ), or R
/��su _---------____ __ _
}}ocation — ddress Assessors Map and Parcel
L yti,� 1p, o Qox' _ 6 a MG ,s 7'8Ns
- - ; --- ---,--------------- - - - — - -- -
y CC - /j caner ——_ — 0 Address `
• J_C� P- , /-ox----------------M--S -`--------�-��---�----------------
Installer — Driller Address
TYPe of Bulldrg-
.. -
Dwelli �S
Other, Type of Building -------------------- No. of Pei sons---------------------1 -------------------=-
IX
Typeof Well -------------------------------------- -- - Capacity------------- ------------------------------------------------------
Purpose of Well
Agreement:
' The undersigned agrees to ins the aforedescribed ind jd ia.1 Ali iu ia;�aidance with the.provisions of The
t
Town of Barnstable Board of ealth Private Well Pcotectton Regulation _ The undersigned further agrees not to
i place the well in operation ntil a Certificate .of Compliance has been i ued by the Board of Health.
1 p
E, 3cd . . /( G
g �G---
;F � S' ned -------------- - ----- �------------- --.� 8-- dace -----------
s ,Npphkation Approv d B � �✓-
}l date
2 A 01hcat�roDisa oved for the folio in reasons:--------------- :-
\\PP PP g . - ----------------------- --------
- —-- -- ----�_— - - - --- - - --- --------�-
�y - date
,fit/'/ �,,h,•
Permit No. Issued -/- '� --------------- ---------------
date ^•.y
BOARD OF HEALTH/ " +
TOWN OF BARN.STABLE a;
C ertif irate ®f Compliance
THIS IS 'TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( r'f
Y- - - - _ -1-e -----------------------------
} Installer /
at-------- J_�oS �r.1— w rc
—` — —— — — — --
has been installed in accordance with-the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit N -- .-_15-Dated- ��"'----- -�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
4
DATE--------- ------ -- - --- -'-' Inspector---------------------------------------------------------------------
S�v'�Tr e
2 A as�Ns
. x
p n
G
N
`o
C'
y;
TOP FNDN. AT EL. 98.9' PROVIDE IF NEC. SYSTEM PROFILE TEST HOLE LOGS
ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN
ACCESS COVER (WATERTIGHT) TO 6" OF FINISH GRADE ENGINEER: FRANK CONERY, PE
MINIMUM .75' OF COVER OVER PRECAST WITHIN:6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 91
WITNESS: BARNSTABLE HEALTH DEPT.:0'
ELEV. 91.5' RUN PIPE LEVEL 2" DOUBLE WASHED- PEASJONE� DATE: 1978 I �P
FOR FIRST 2' �/ 3' MAX. PERC. RATE _ < 2 MIN/INCH
EXtSTtNG �Q� IP
GALLON SEPTIC go,I' t* 89.0fr. ' CLASS ! SOILS P#"ITT LOCUSTANK (H- 1O ) GAS 'RE-USE BAFFLE 88.49' 000 88.32 [� 0 Q-O 0 p m r o
88.T7'/' o0 P0�
6" CRUSHED STONE OR MECHANICAL = I= Q Q 0 0 Q
_ 4 COMPACTION. (15.221 [21) 1 g 2' 0 O CO C? f� C] L7 !� 0 86.17' 0„ Q E9 E 4' 0" ELEV.' ,
DEPTH ES FLOW - ( 1-3 %.SLOPE) ( % SLOPE) - -3/4": TO _1 1/2 DOUBLE WASHED STONE-- A SCHOOL
TEE SIZES:
INLET DEPTH 10" LOAM LS
14" 12 8" 1OYR 2/1
OUTLET DEPTH = LOCATION MAP NTS
LEACHING B
FOUNDATION-- EXIST. SEPTIC _TANK- 12'_ D' BOX 17' FACILITY LS ASSESSORS MAP 46 PARCEL 119
{ 6.7' HARDENING
*THE -INSTALLER -SHALL VERIFY THE - 24 7.5Y4 4/6
LOCATIONS-OF ALL_U_TILITIES AND ALL_ 89.4 36 89.4
BUILDING SEWER OUTLETS AND-ELEVATIONS
PRIOR TO INSTALLING_ANY PORTION OF
SEPTIC SYSTEM �'1 LOT 15
34,218t SQ. FT.
TEST HOLE #2 PERFORMED 4/5/04
p5 >> -
THE INSTALLER SHALL . '1- p : C TO CONFIRM SOILS PRIOR TO
CONFIRM SUITABLE SOILS oo, 79'4 INSTALLATION (ENGINEER: AH OJALA,
FOR 5' BENEATH LEACHING I EXIST.• WELL SAND C-MS & PE)
FACILITY ELEVATION PRIOR I BENCH MARK - TOP OF CONC. �40474 GRAVEL
TO INSTALLATION.
CO OD oo + �g° BOUND ELEVATION= =- 104.7 � 2.5Y 6/6
_. ._., .w.. �.._
CR 84.9 **PER COMM WATER
DEPT., LOCUS IS ON
019 TOWN WATER-
1 a.7-®+ei :7 + 04.4 144+. 79.4 120" 82.4'
-� EXIST.
�s.6 ,�g0 WELL** � / � /'" k03•8 NO WATER. ENCOUNTERED NO WATER ENCOUNTERED NOTES:
�� 00.9
110 90.1 / SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) 1 . DATUM IS APPROX. NGVD
co /
/ DESIGN FLOW: 3 BEDROOMS ( 110 GPD) = 330 GPD 2. MUNICIPAL WATER IS EXISTING (CONFIRMED THROUGH WATER DEPT)
'o + 95.2 102.7 USE A 330- GPD DESIGN FLOW -- __, -y-
` 3. MiNIMt�M PTPE-PITCH TO BE "i/8" PER FOuT. '
-10.
+ 91. + e ���� �: SEPTIC TANK: 330 GPD (2) = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHK 1-1 10
0 0 + 3.7 J�� � 1000 5. PIPE JOINTS TO BE MADE WATERTIGHT.
�_ USE A GALLON SEPTIC TANK (RE-USE EXIST.)
+\1 �P� 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
�/ LEACHING: ENVIRONMENTAL CODE TITLE V.
`oF� + 91.2 \ + ss 971 J6�7 o / f SIDES: 2(30 + 9.83) 2 (.74) = 118 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT
-+- °' 0) `� O _ _ TO BE USED FOR ANY OTHER PURPOSE.
4(016.9 rn 30 x 9.83 (.74) = 21$ 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
�e�s.o u � BOTTOM:
c�
p� F 5.3 '' 1 TOTAL`. 454 S:F. 336 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
0 1 °��' 100.5 INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
T -2 / USE .(2)-.500 .GAL. _LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH.
EQUAL) WITH 2.5' STONE AT SIDES 4' AT ENDS AND 5'
&.3: . o 10. PUMP & REMOVE (OR. FILL W/CLEAN. SAND)- FAILED SEPTIC SYSTEM
9j�'LC + 10 .a a� �\ 8 oa.2 ,100.0 BETWEEN' UNITS
) 0 0,00 O ,
o. 91.5
EXIST. = _ BOSUN_'S _ WAY
. cD -
AREA OF EXISTING a) DWELL. 99.2 LEGENDTITLE 5 SITE PLAN_ -,
FAILED RECHARGER TOP FNDN -
LEACHING FACILITY + 91-5 DECK - EL.
+ 91.6 98•9' �.��� _ � 100.0 PROPOSED SPOT ELEVATION OF c 1
100x0 EXISTING SPOT ELEVATION 22 BOSUN S WAY
- 98.1 = IN THE TOWN OF:
'a- 0 98.
moo. 1 AREA �T 100 PROPOSED CONTOUR MARSTO N S MILLS BAR N STABLE
+ 91.4 \ �
DRAIN �r �T �\ 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI CONSTRUCTION/TRONET
DRIVE �
+ �1.3 96.9 97.0 96.9
9 9 �� 20 0 20 40 60
�6.0 BEARD OF HEALTH
+ APPROVED DATE
MA SCALE: 1" = 20' DATE: MARCH 29, 2004
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