HomeMy WebLinkAbout0061 BRANCH TERRACE - Health 61--Branch Terrace, ` IN,r
Marstons Mills P
f
i
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VII.,IL LAGE S ASSESSOR'S MAP 8c LOT-1 Zt0 030
INSTALLER'S NAME&PHONE NO, J�
SEPTIC TANK CAPAC V
—,&FFACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between.the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If ary^tlands exist
within 300 feet of leaching facility)
�1 io 3 Feet
Furnished by 1 I
z.N
S
G^' TOWN OF BARNSTABLE
LO('ATIONC�I ,T�/�. �'/� L ?` G� SEWAGE # 4�'� �Ef
VILLAGE /'YIAZ54 013 rf' 1 15 ASSESSOR'S MAP &LOT/
WSTALLER'S NAME&PHONE NO. -r; hP 500
''SEPTIC TANK CAPACITY
r
tsEACHING FACILITY: (type) 3 -9-6 Eat e f S (size) 330
NO.OF BEDROOMS
OR OWNER
PERMITDATE: " `�� `7`z4 COMPLIANCE DATE:
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
r_
,
Commonwealth of Massachusetts IC2& -030
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Branch Terrace _
Property Address
Stephanie Brown
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 5-10-18
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.
Important:When A. General Information �� Q
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return Name of Inspector
key.
_B&B Excavation
k Company Name
374 Route 130
Company Address
2� Sandwich _ _ _ Ma___ 02563
City/Town State Zip Code
(508)477-0653 _ S113747
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails -
❑ Needs Further Evaluation by the Local Approving Authority
5-10-18
Inspector'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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""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.
15ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i - -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 61 Branch Terrace —
Property Address
Stephanie Brown
Owner Owner's Name
information is Ma 02648 5-10-18
required for every Marstons Mills _
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
t
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
The system was in working order at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is required fcr every Marstons Mills ' Ma 02648 5-10-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpsialarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ 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):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is Marstons Mills Ma 02648 5-10-18
required for every —
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
t r less than 5 m provided that no other failure criteria are triggered. A co of the analysis must
0 o es pp , p gg copy y
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1h day flow
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Branch Terrace _
Property Address
Stephanie Brown _
Owner Owner's Name
information is required for every Marstons Mills. Ma 02648 5-10-18
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes 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 2000gpd-
10,000gpd.
❑ 2 The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
.necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
AMUMW Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 61 Branch Terrace _
M
Property Address
Stephanie Brown
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5-10-18
page. CitylTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
t
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)]
D.D System Information
- Y
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/GPD _
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is Marstons Mills Ma 02648 5-10-18
required for every —__ _ —
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
H
Number of current residents: 3 —
Does residence have a garbage grinder? ❑ Yes ® No
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 d See below
9 ( Y 9 (gp ))�
Detail:
2016-38,000gallons 2017-32,000 alb lons
Sump pump? ❑ Yes ® No
Last date doccupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ElYes ElNo
" Water meter readings, if available: -
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM " 61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is ever
y Marstons Mills Ma 02648 5-10-18
required for _ —
Q ry —
Cit !Town State Zip Code Date of Inspection
page. Y P P
D. System Information (cont.)
Last date of occupancy/use` bate
Other(describe below):
General Information
Pumping Records: °
Source of information: Owner-date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? —
Reason for pumping: — -
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
El 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 [/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 61 Branch Terrace _
Property Address
Stephanie Brown
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5-10-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1996 per permit
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'8"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 8
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000gallons
Sludge depth: 8
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.N 61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is
required for every Marstons Mills _ _ _ Ma 02648 _ 5-10-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 26
3„
Scum thickness
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 13"
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.):
The tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in
need of pumping at this time and should be pumped every two years for maintenance.
Grease Trap (locate on site plan):
NA
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is Marstons Mills Ma 02648 5-10-18
required far every _
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA —
Material of construction:
❑ concrete. ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: -- ---- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a,
H0 61 Branch Terrace �
Property Address
Stephanie Brown
Owner Owner's Name
information is
required for every Marstons Mills Ma _ 02648 5-10-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 011
-
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.);
D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not
show signs of back up.
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.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 61 Branch Terrace _
Property Address
Stephanie Brown
Owner Owner's Name
information.is Marstons Mills Ma 02648 5-10-18
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: (3)infiltrators
er
❑ leaching fields number, dimensions: -
❑ overflow cesspool number: - ----
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was %
full when viewed.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
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
t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' 61 Branch Terrace
Property Address
P Y
Stephanie Brown
p - -
Owner Owner's Name
information is Marstons Mills Ma 02648 5-10-18
required for every — -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.0 61 Branch Terrace _
Property Address
Stephanie Brown _
Owner Owner's Name
information 3s required for every Marstons Mills Ma 02648 5-10-18
- -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
Back
A B
0 AA-23'
A AB-32'
0 AC-24'
BA-20'
BB-30'
BC-45'
C B
I
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M 61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is Ma 02648 5-10-18
required for every Marstons Mills _
page. City/Town State - Zip Code Date of Inspection
D. System Information (cony.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: No GW 4' below SAS
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: Permit Dated 6-18-96
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:
Plan on file with BOH.
x -
r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
S
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 61 Branch Terrace
Property Address
Stephanie Brown
Owner Owner's Name
information is Marstons Mills Ma 02648 5-10-18
required for every —
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
030
No. Fee $ 40.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(pprfcation for Mtgool *pgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair�X)an On-site Sewage Disposal System at:
ocation Address or Lot No. 5 4 0— Owner's Name,Address and Tel.No. 8—540=2880
�1 Branch Terrace Robert Cummings
Marstons Mills ,Mass . 28 Plum Hollow Road E. Falmouth,MA
Installer's Name,Address,and Tel.No. 5 0 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
Joseph P. Macomber Jr.
Joseph P. Macomber Jr. Box 66 Centerville Mass. 02632
Box 66 Centerville Mass. 02632 9
Type of Building:
Dwelling X No.of Bedrooms 3 Garbage GrinderIffo )
Other Type of Building No. of Persons 3 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 0 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil Sand & gravel
Nature of Repairs or Alterations(Answer when applicable) Adding 3:330 Re chargers to an
existing tank & pit" ,
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 issue by this B d Heaph
Signe n4 a Date
Application Approved by
Application Disapproved for the following reasons
Al
Permit No. V L Date Issued
0
No.
Fee $ 40.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for -Migogal 6p5tem Construction Veinfit
Application is hereby made for a Permit to Construct( )or Repair TX )an On-site Sewage Disposal System at:
ocation Address or Lot No. Owner's Name,Address and Tel.No. 5 0 8-5 4 0=2 8 8 0
1 .Branch Terrace' Robert Cummings
Marstons Mills,Mass. 28 Plum Hollow Road E. Falmouth,MA
Installer's Name,Address,and Tel.No. 5 0 8-77 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8_7'7 5_3 3 3 8
Joseph P. Macomber Jr. Joseph P. Macomber Jr.
Box 66 Centerville Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling X No.of Bedrooms 3 Garbage Grinder)go )
Other Type of Building No. of Persons 3 Showers( ) Cafeteria( )
Other Fixtures tr
Design Flow 330 gallons per day. Calculated daily now 3x1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil Sand & ?ravel
Nature of Repairs or Alterations(Answer when applicable)
Adding 3--330 Rechargers to an
existing tank & pi&t
r
Date last inspected:'
f �
Agreement: r
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 issu=this d�zo!ri�iw,
Signe1/ /1 a Date 6111 R/0 H
Application Approved b
Application Disapproved for the following reasons KI a
Permit No. E Date Issued
f
— -- ----------------------------_._— --- -- — -
}
THE COMMONWEALTH OF MASSACHUSETTS,,``
i
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Corr, plian:ce
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replacedyX )on
byJ.P.MAcomber & Son Inc. for Robert Cummings
as 61 Branch Terrace Marstons Mills Mass h Ve constructed in accordance -
with the provisions of TitW5 and the for Disposal System Construction Permit No. dated a► f
Use of this system is conditioned on compliance with the provisions set forth Belo .
I� No. � —' �A'v
r 030 Fee 0.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
+ lwigozat *potem Construction Permit
Permission is hereby granted to J.P.Macomber & Son Inc.
to construct( )repair(XX)an On-site Sewage System located at 61 Branch Terrace MarstoneMIZLS
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. r
t f
All construction must a competed within two years of the date below. d
l�r r /
f Date: Approved by Ce,
y
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I Joseph _P. Macomber Jr., hereby certify that the application for disposal works
construction permit signed by me dated 6/18/96 , concerning the
property located at 61 Branch Terrace 71ar-stans M; 31 c Mo meets all ofthe
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is :4 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED i DATE: 6/18/2
LICE ED SEPTIC SYSTEM INSTALLE/INTHETOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
xisting 1000 -
gallon leach pit
Existing 1000 Install 1-D-Box
gallon tank. 3-330 Rechargers
With drip pipe.
61 Branch Terrace Marstons Mills
O 23 � t
NPry LXCk
16'
NEW DECK {
40'
FEP
22' 24' BAS
BMT
10'
— New c
Gam! hASf- w) lc4P
2 U� of i
lib ON 6en4,-r Alt S-�va S
GABLE VIEW ufnC."e `rieeS 'Usev+c> here
NEW WINDOWS ` G>✓�\��g Par-TT-_eS
REAR 24r)
ENTRANCE �`9 P D f PJ Frbr�tT
SLIDER NEW
V'G
USIN6 �j�C in Ce-1. 1171� i
J 1
— Uszn46 R 13 inl wa-1l S < IF 6-,.
w4�, un pzr �3arrrtzr.
1(p U�1 CPA/ FRONT HOUSE
NEW WINDOWS.
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