HomeMy WebLinkAbout0121 BRACKEN FERN ROAD - Health 121 BRACKEN FERN ROAD
MARSTONS MILLS
A= 042-034 /
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No. / Fee 74�
THE COMMONWEALTH OF MASSACHUSETTS Entered in com uteri
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Bispo8AY *pStrm Cunstrurtion Permit
Application for a Permit to Construct( ) Repair Y Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. FlEAN RD Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 4. H' 1 (� MM
Installer's Name,Address,and Tel.No.SG$"tf1Z-Steil Designer's Name,Address,and Tel.No.
°C• c t�►�17iE Ra T iD O04 00
Type of Building: j
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Buildings L [ �,L No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 4�4 gpd
Plan Date Number of sheets Revis on Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) —1 la_)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
igned Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit NO. �� Date Issued
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in con, uter:_i�
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplicatlon for Disposal 6pstem Construction 30ermit
N,
Application for a Permit to Construct( ) Repair( Upgradd( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. (a{_(j4AeV j FAN Owner's Name,Address,and Tel.No.
Elm
Y Assessor's Map/Parcel,
D
Installer's Name,Address,and Tel.No.$'p B-���j-�$1"( Design is Name;' ddress,and Tel.No.LIS! ,
� l�oEWL7JEl Ra�T tj ��� ,;i PIA- i
Type of Building:
S
Dwelling No.of Bedrooms U, Lot Size sq.ft. Garbage Grinder( )
Other Type of Building !L% No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided A 1 A gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ,..
Date last inspected:
KAgreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
4, accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
`e 'gned Date
Application'Approved by Date
I t
Application Disapproved by Date
for the following reasons F
Permit No.c9pl9 . .5 Date Issued
°- THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance ! k
THIS IS TO CERTIFY,that the O -site Sewage Disposal system Constructed( ) Repaired OO Upgraded( )
Abandoned( )by C 'll
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NAZ?_--�S dated
Installer0AP6Q,X()i6 09 6cio (2Z Designer
#bedrooms A) 1 2 Approved design flow , ) gpd
r
The issuance of thi pe it shall not be construed as a guarantee that the system will function a(/� esigned. n r
Date ` r1 Inspector ( (1 �/)
Fee
THE COMMONWEALTH OF MASSACHUSETTS
;l PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair X) Upgrade( ) Abandon( )
System located at ] ) P E2A / -P k4, G`TDa ,r k I ,/C'
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local,provisions,or(speci conditions.
7
Provided?Construction rn be completed within three years of the date of this p rmit.
Date ) Approved by
11/12/2019 ShowAsbuilt(1700x2800)
�1 L TOWN OF BARNSTABLB
c-lOCAT1ON•�a� /,3",—/,'- "SEWAOE#PCs
VILLAGE /y,4W /XIS ASSESSOR'S MAP LOT6 2�PT
�WSTALL8H9 NA48 G PHONE NO./SJ��7�i��ne� 1-)J
d
QSBP1iD TANK CAPACITY 4am,
LEACHING PACIUTYA,YP)
.. NO.OF BEDROOMS � PRIYAT13 WELL/OR PUBUC WATER_
BUILDER OR OWHRfl Tn.
DATE PERMIT LASUEDr
DATE COMPLIANCE ISSUED-
VARIANCE GRANTED:Yn No
IJIVVL,kmv ryY .
f�VfY
3? 2s
37
https://itsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=042034&sq=1 1/1
0.1}a- 03LI
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
Information is
required wiredred for every Marstons Mills MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
nu�HlOFI4lr tf,,,
Important:When A. Inspector Information
filling out forms p S��r�t.�a� ;�, '••.�y
on the computer, �:' JA M ES G
use only the tab James D.Sears =�;
key to move your Name of Inspector g ; SEII
cursor-do not *'•
use the return Capewide Enterprises �,.•o o.. �*
key. Company Name
153 Commercial Street i�q�RF S INS ON
r� Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
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
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
�Cid�La a— " 11-13-19
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of Inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
15insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 19
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
is
information Marstons Mills MA 02648 11-13-19
required for every
page, City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6.
1) System Passes:
® 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 exisi.Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank D Box and pit.
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 ❑ NO (Explain below):
t5insp.doc-rev.712612018 Tille 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
-Pro Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information is MarstonS Mills required for every MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cons.)
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 ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO(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:
15insp.doc•rev.712612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
`11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road .
Property Address
Lisa Miller
Owner Owners Name
information is required for every Marstons Mills MA 0264E 11-13-19
page. CityrrDwn State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
Cessp
ool poor privy is within 50 feet of a bordering 9
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 AU 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.712 612 01 8 Thle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Acdress
Lisa Miller
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in aegapmoi is less than 6"below invert or available volume Is less
than'/z day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than S 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 falls, 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 C.4.
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
t5tnsp.doc•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Dlsposal System•Page 5 of IE
Commonwealth of Massachusetts
U
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
informationis
requiredairedfor every Marstons Mills MA 02648 11-13-19
for
page. CItylTown 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.cloc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 1d
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v � 121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
iequir dfo is Marstons Mills MA 02648 11-13-19
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
1000 Gal, Tank D Box and pit.
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
Seasonal use? ❑ Yes ® No
Water meter readings,if available last 2 ears usage 2017-46,000Gals
( y g (gpd))' 2018-34,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc•rev.MUM18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11-13-19
page. City/Town State Tip 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: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
*nsp.doc•rev.7128l2018 Title 5 official Inspectlon Form:Sutsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f
121 Bracken Fern Road
Property Adcrtess
Lisa Miller
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy.of latest
inspection of the 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:
1989 Permit#89 -658/ 11-2019 New D BoX.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 18"
feet
Material of construction:
❑cast iron ❑ 40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
t5insp.doc•rev.7l261201 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 1a
r11 63Bpd VDJ JU (%4,•C7 C I M7 1.1 Ar)K1
Commonwealth of Massachusetts _.
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information is every
Marstons Mills
required for eve MA 02648 11-13-19
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
B. Septic Tank(locate on site plan):
8r
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene y ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness V.
Distance from top of scum to top of outlet tee or baffle 8
Distance from bottom of scum to bottom of outlet tee or baffle 171,
How were dimensions determined? Asbuilt-Plan-Tape
_Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level. Tank and covers at 8". In and outlet tee's. No sign of leakage or over
loading.
t5insp.doc•rev.71262018 Tile 5 Official Inspeclion Form:Subsurface Sewage oispooal System-Page 10 of 18
L t abed xea .Iu 047'c7 9107 +.1 AM
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information Is required for every Marstons Mills MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
61nsp.dac•rev.7/2812018 Title 5 Official Inspedon Form Subsurface Sewage Disposa'System•Page 11 of 18
• -.r..a
Commonwealth of Massachusetts
. Title 5 official Inspection Form
/< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of Sox, etc.):
D Box is 16"x16"-13" below grade More line out. Box is new 11-2019 w/cover at 6"
I5nsp.doc•rev.712612018 Title 5 Official.nspeclion Form:Subsurface Sewage Disposal System-Page 12 of 18
FL abed xe-1 AH QV97 ALn? 17L. AON
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
Wormrequired
I[G is Marstons Mills MA 02648 11-13-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass,
11. Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located,explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc rev.712612018 Title 5 0fficial Inspeclfan Form:Subsurface Sewage Disposal System•Page 13 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
E
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information Is required for every Marstons Mills MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. Pit W/2'Stone. Pit and cover at 21" below grade. Level in pit at 40" below
inlet . No sign of over loading or solid carry over.
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.):
t5lnsp.doe•rev.712612018 Title 5 Official Inspection Forth:Subsurtace Sewage Disposal System•Page 14 cl'8
Cl abed
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface`Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 11-13-19
page. CitylTown 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.):
15insp.doc•rev.72512018 Title 6 Official Inspection Form Subsurtaoe Sewage Disposal
g p System•Page 16 of 78
�G-J
Commonwealth of Massachusetts
le Title 5 official Inspection Form
li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information Is Marstons Mills
required for every MA 02648 11-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
-� - 32-�" o
-a = 3 `' L5
t5lnsp.00c•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
/i. afed
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
information is MarS10n5 Mills
required for every _ MA 02648 11-13-19
page. CityrTown State Zip Cade Date of inspection-
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'
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: 10-27-89
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 10-27-89 12' No G.W. Bottom of pit at 8' below grade. Bottom of pit at 4' above
T.H. Depth.
i
M
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15insp.doc-rev.7/2812018 Titles Official Inspection Form:Subsurface Sewage OlWaal System•Page 17 of 18
O I AFIOft
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r _i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-� 121 Bracken Fern Road
Property Address
Lisa Miller
Owner Owner's Name
Information is every
Marstons Mills
requiredioreve MA 02648 11-13=19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 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
�oo
AT-
NO
G.w
15lnsp.doc-rev.112612018 TiOe 6 Official Inspection Forth:Subsurlace Sewage Disposal System-Page 18 of 18
61, a5ed Yl?� HH Rt7:F7 61,07 b I. AOKI
TOWN OF BARNSTABLE
LOCATION/v? ]jneI4 c A/-JSEWAGE # -
VILLAGE ASSESSOR'S MAP &. LOT6
INSTALLER'S NAME & PHONE NO. ���� / ��'�/���kv� `f77
ASEPTIC TANK CAPACITY 6600
LEACHING FACILITY:(type) ID%"74 (size) l 0cd
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER `
BUILDER OR OWNER_) A
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
cK6N
36
x - �
ti
i A
No....C21..�...J... Fis....�,,� •r
THE COMMONWEALTH OF MASSACHUSETTS L - 3Y
BOARD OF HEALTH
�i7..................OF....... ..................................................
Appliration for Biipniittl Workii Touts rur#inn rrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•---------••--- ---- -----------------•---..•::*..---• ....._..._......
_ Location-Address or Lot No.
.�44C!V2A- 1S.._�v►i ................. 1 /� ...............olj _6:q �' C[2..1 , .............
Owner �O b en .�J�J, �C ec9 J/P Address
a :...................... --------------- ...111cll.�............................................
Installer Address
Q Type of Building Size Lot...... l.' ....Sq. feet
U Dwelling—No. of Bedrooms.......I_h c_<_________________________Expansion Attic (/1/0�) Garbage Grinder 04)
Other—T e of Building No. of persons............................ Showers — Cafeteria
0.' Other fixtures -------------------------------•----------------------.-----•-------•-•------•--•-••--•-----••------••••••--••---------------•-------------...........
d
W Design Flow..................................5-!S----gallons per person per day. Total daily flow_____---.-_-----_--_----3.??.C>.......gallons.
W Septic Tank—Liquid*capacity.[C`M-gallons Length8_:.-C_.___ Width._e_-1II... Diameter................ Depth_--.-_w.....
...... Total leaching area...................s ft.
x Disposal Trench—No. .................... Width.................... Total Length.................... g q.
Seepage Pit No._-,arrLe.--------- Diameter......ZOa_--___- Depth below inlet..... ........... Total leaching area.... 7._sq. ft.
Z Other Distribution box (.<) Dosing tank ( )
Percolation Test Results Performed by.-_%,__�Jrs �L,i............................................... Date.....612?IFl j......--....
Test Pit No. 1......... .......minutes per inch Depth of Test Pit----zt ....... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.__.
® W
0 Description of Soil....a.-z .....Tef' L-oavn
-•.................•--•--•-------•Z-- . ......
----•--►M_C_Cf.LU tea.--- ----•---•----------------------•-•--------------------•---•--------•-•------•• .....WILSOJ!l_.
UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------- No:3021��
.............................................-...............................................................................................................................
Agreement: IA ..:.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor
the provisions of TITLE S of the State Environmental Code—The undersigned further agrees not to place the eo
system in operation until a rtificate of Compliance has been issued by the board of health.
Signed - 1...`-� "�-.
------------------ --- ---------------- - gce-.........---
AApplication Approved B ..."2 ---- ---- .,------- --------------------------------------------------------------------- --------- 7
PP PP Y Date. ......
Application Disapproved for the following rea cons: ------__---------------- ----------------- ----------------- -- .------................--... ----...-- --------
-------'--------------------------------------------------------------------- - ---------------------------------------- --- -- ----------------- -- --------------- -- --- ----- ----------- -----------------------
Dace
Permit No. .°1....�...�` .�............... Issued .
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........?�42.t% a..................OF....... �c i' 7�g-----.............................................
Appliratinn for Disposal Works Tonstrur#inn jJrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
ep
.�.�.............. . ° :-••. ...................c?....= ........--- •-------•---..•.................------...
Location-Address or Lot No.
�tcn Q -K '�m'i Fie --- ,[%/de/ r.r... rii l2el........................................
- --;-- /
W Owner �•-�c�I 13 j. lr.c s:.�n�r�r-✓/_l�,/A7S Address
T- R I ✓ <
c �
Installer Address
Q Type of Building Size Lot----- ....Sq. feet
U Dwelling—No. of Bedrooms.__..._ 2�rG........................Ecpansion Attic (/l�) Garbage Grinder (/l�s)
114 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -`-•-••--•-----------------------------•---••-•---•------------......-•--
Q
W Design Flow......................................:.gallons per person per day. Total daily flow......................... ✓ .......gallons.
r-i It
WSeptic Tank—Liquid capacity.i-C—M.gallons Length43'-G.'_._ Width.. �" .,. Diameter................ Depth�.�:
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...0:�..-._-_-- Diameter....../4 _- Depth below inlet_........._.._.. Total leaching area...:`=S ..sq. ft.
Z Other Distribution box (JC) Dosing tank ( ) /
Percolation Test Results Performed by.... lce cc�b.l... ................. ----------- Date..... ,/ ............
Test Pit No. I......22�<_......minutes per inch Depth of Test Pit..../Z........ Depth to ground water.....:...
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. .
---------------------------------•--------------•----........................I................................................... ..............
O Description of Soil..... .-Z.0 1°!?. O�''� o STEPHEN
(4 -••..................•--------....2..---6 Su[QsOA...I I4.y.................................................................................. :� .... ALLYN
ca .wf[:S()K..
�', 1 �......-•tiY1c ,w-vx... 3'n`,Q ... A ilo:3t}Y 6�
U Nature of Repairs or Alterations—Answer when applicable....................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac ordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a ertificate of Compliance has been issued by the board of health.
1 .
Signed .. .. � � � ---- "r ----------- '"...-- -. --------------
- Date
Application Approved By ........-- Date";�."J..
Application Disapproved for the following reasons: ............ ............. ............................ ..... . ........................... .. ....... .........
.-------- . -- .........
-------------------------------------------------------------------------------- ----------------------------------------------------------------------a---------....------------ ---------............ ..........------
/� � Date
PermitNo. ...---- - ..' &_! ---�--------------------- Issued -------------------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------ K) ............................. OF .._..-......7.�'s'r/� -- ........... ........
(IlVdifiraz#e of C11oxttylinu e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
b =''d� � "� " - � � '"" -------------------------------------- ----------------- ---------
Installer
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. .......- ��..-.4..s... ...... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------- ------------------------------------ -- -------------------- Inspector ....------............------------------------.......--------............. -- ------------
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
,/t3 is ...........OF.......•, . .b'r?!'ti?''..r�-/..� .-----•--......... r
No..... .1. S loS FEE.../.... ............
Disposal orko Tonotnutio rrnti#
Permission is hereby granted................. ..:_ ... ' .......................' ' ................................................
.
to Construct ((_,.)��Repair ( ) an Individual Sewage Disposal System
at No,vl rt� , •e�. r�F ,� }`� <-�, . � .....'.......... ,�C�/W-�.....------•-••-•---•--.
..-•-----------•--••-
Street f
as shown on the application for Disposal Works Construction Permit No ...... ��....... Dated..........................................
................................. ..------------.....--------•--••-•-----•----•--._
�oardf Health
DATE................�'�_ v ............................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 7
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10/2412019 ShowAsbuilt(1700x2800)
'01 L I TOWN OF BARNSTABLE
iJ,t .00ATION,;o:J
S2 n ,',u .iv EwAGE r
',VILLAGE /'/" "' "VL ASSESSOR'S HAP&LOT6 2,07
INSTALLER'S NAME&PHONE NO./9,4,1//>v i14 f y77
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\^SEPTIC TANK CAPACITY 40—
LEACHING FACILITYAtype) /cif (size) 6,1
NO.OF BEDROOMS +? PRIVATE WELL/OR PUBIC WATER
BUILDER OR OWNER T,—,r If
DATE PBRHIT ISSUED:
DATE COUPLIANCE ISSUED.
VARIANCE GRANTED: Yea No
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