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0014 BRIDLE PATH - Health
14 Bridle f.ath Marstons Mills_ P A =-150 090 J i 1 i s Commonwealth of Massachusetts ha 090 I,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 page. Citylrown 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. A. Inspector Information r�10_7I Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number.. f B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);.I 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 8/9/19 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 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 .a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bridle Path I Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19. page. Cityrrown 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: ® 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: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every. Marstons Mills MA 02648 8/9/19 page. Citylrown 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=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills. MA 02648 8/9/19. page. Cityrrown 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 failiure 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-- (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 14 Bridle Path Property Address Coyle Owner Owners Name information is required for every Marstons Mills MA 02648 8/9/19 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 cesspool is less than 6" below invert or available volume is less than Y2 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.1 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 II of a public water supply well t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts. ,IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 page. City/Town 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 ❑ E 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? E. ❑ 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 r Commonwealth of Massachusetts i? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a u 14 Bridle Path Property Address, Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. ResidentiaLFlow 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: Number of current residents: 2 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No. Last date of occupancy: occupied Date t.5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 t I Commonwealth of Massachusetts- re Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills. MA 0264.8 8/9/19 page. Citylrown 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: Pumped summer 2017 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Pumped every 3 yrs per owner t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 l Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 page. Cityrrown 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: Original septic tank per age of the home, new d-box and additional leach.pit installed 2002 per record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insP.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts- (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property.Address Own Coyle er Owner's Name information is required for every Marstons Mills MA 02648 8/9/19. page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 6. Septic Tank(locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet cover raised to 6 of grade, outlet cover is under brick pavers and was not accessed If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: n/d Distance from top of sludge to bottom of outlet tee or baffle n/d Scum thickness n/d Distance from top of scum to top of outlet tee or baffle n/d Distance from bottom of scum to bottom of outlet tee or baffle n/d How were dimensions determined? n/d Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system, sludge and scum levels at the outlet are presumed to not be excessive based on the pump history of the system t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts- ,, (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 page. Cityrrown 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 thlickness 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 t5insp.dac-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts- �b F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is ii required for every Marstons Mills MA 02648 8/9/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8.1 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.): D-box is 2' below grade, cover raised to 1', no adverse conditions observed 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owners Name information is required for every Marstons Mills MA 02648 8/9/19 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: 2 ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form t� o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 page. Cityrrown 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.): The pit depicted as"C" is the original one per file, it was not excavated the soils in the area are compact and dry, pit depicted as "D" is the one installed in 2002 per file, it was excavated,it is 2'6" below grade, cover is raised to 12"of grade, the pit was half full, no indication of past hydraulic 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 �. ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 page. Citylrown 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 I ' Commonwealth of Massachusetts ►F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bridle Path Property Address Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/19 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 3 ,` ' ` i C=� r c LA t t� Ch t5insp.coc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 l- Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Bridle Path Property Address. Coyle Owner Owner's Name information is required for every Marstons Mills MA 02648 8/9/% page. Cityrrown 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: >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: n/a Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Nothing in file but 2002 inspection report ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, the site is at 73'msl and nearby surface water is at 43.'msl You must describe how you established the high ground water elevation: See above 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 c Commonwealth of Massachusetts e Title 5 Official Inspection Form ~ 15 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bridle Path property Address Coyle Owner Owner's Name information is TequiredIrforevery Marstons-Mills MA 02648 8/9/19 page. Cityrrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 t TO OF BARNSTABLE TION fL ��t CG� � SEWAGE # q /1 Ar5�0r1 /1 ilk: ASSESSOR'S MAP & LOT 0 -G7v TALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �� `� LEACHING FACILITY: (type) s��'�XG P1 -s (size) N0. OF BEDROOMS ,Q ,BUILDER OR OWNER PERMTTDATE: °2 COMPLIANCE DATE: "=Id Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �: P� Q.�.k a� � o a � a � aa6a�v 3 a ao ai 3a� �/i 9 s s� OF BARNSTABLE Pr !! SEWAGE # I�.LAf.,>r/�VJAr sl'bn M t t IS ASSESSOR'S MAP & LOT l 5� 05 O INSTALLER'S NAME&PHONE NO. a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ram' X 1 S (size) NO. OF BEDROOMS 3 BUILDER OR OWNER �o 41WI 0 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility)._:,_ Feet Furnished by�/1 SDu. �On �0/� F 16 3 a � A t3 ao p� y a� yi s as sg i4o. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓V Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Mgooar *p.5tem Congtruction Permit Application for a Permit to Construct( )Repair Xupgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. j %R i A, � Owner's Name,Address and Tel.No. Assessor's Map/Parcel 130 — c� 19 Rj l� K�,6W dill . . Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 6U r�(`st v ai Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures " Design.Flow_ gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4x- J W 40 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 iss d by is Board of Health.. Signed Date Application Approved by Date 0 a Application Disapproved for the following reasons Permit No. Jod ay Date Issued u 0 Fee � Entered in computer: TH'E COMMONWEALTH OF.MASSACHUSETTS --_._ l Yes r PUBLIC HEALTH.-DIVISION -TOWN-OF BARNSTABLE., MASSACHUSETTS 0(pp;firation for Oigpo$at *pgtem,,Congtrurtion Permit--" Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System El Individual Comp nents Location Address or Lot No. rS! r, � Owner's Name,Address and Tel.No. 4 F Assessor'sMap/Parcel ' f 9 �#/ 1 j" Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.7 T�yPe of Building: g r Dwelling - No.of Bedrooms Lot Size sq.ft Garbage Grinder( ) Other Type of Building No.of Persons Showers yp g ( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. t .,,,`Plan.Date' Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repaid;or.Alterations(Answer when applicable) ."L�r1i 4J Ank W Y O h A)& 4V 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 iss WI y this Board of Health. Signed r ^`e'. ,Date (I biak Application Approved by XJ u-, Application Disapproved for the following reasons Permit No.�Ud Date Issued l ul-7/a M---- ------.-.---------.---.----- . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS �Cettifirate of (Compliance ti3O L, 0 THIS IS TO CERTIFY,that the On ite Sewage Disposal System Constructed.( )Repaired <)Upgraded( ) t Abandoned( )by u at has been constructed in accordance 'with the provisions of Title 5 and the for Disposal System Construction Permit No.2 w,)- 11 S Y dated /a h1q> Installer /l M[)U c Designer The issuance oJf this permit shall— b ion as d si e construed as a guarantee that the Sys will functgned. Date 1 /1I I0 Inspector r r r ---------------------------------------- No. c')0 0.7 " 'r ti Fee s s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS ;Ditpogar *p5tem Conttrurtiou permit Permission is hereby granted to Cons t( �Xr )Upgrade( )Abandon System located at p £ KORNEEwo �l'Y71 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 must be completed within three years of the date of thi' rmit. Date: /0 /0 Approved-by._ . e ll TO OF BARNSTABLE SEWAGE # a0va" CI J� LOCATION 6 D VILLAGE S�On M� S ASSESSOR'S MAP & LOT�� INSTALLER'S NAME&PHONE N0. G6��a� �U+"'iA�1 SEPTIC TANK CAPACITY day yJ' �OX (�epAi LEACHING FACILITY: (type) �S (size) NO.OF BEDRQOMS BUILDER OR OWNER O� A i j 10 PERMIT DATE: 1 J I2 I°2 COMPLIANCE DATE: v Z 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 ,j on site or within 200 feet of leaching facility) Feet any wetlands exist Edge of Wetland and 4eaching Facility(If Feet within 300 feet of leaching facility) i Furnished by Il Q i i a n a ao a� 3 OL y as sg IL COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED rrT 2 4 2002 TOVVN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 14 Bridle Path P Marston Mills. MA 02648 Owner's Name: John Alladio Owner's Address: Date of Inspection: October 4, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 150 Osterville,MA 02655-0049 Parcel: 090 Telephone Number: (508) 862-9400 Lot:3 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes NQeft Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Date: October 11, 2002 The system inspector shall sub 't copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Bridle Path Marston Mills, AM Owner: John Alladio Date of Inspection: October 4, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditional) Passes: Y Y One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Bridle Path Marston Mills. MA Owner: John Alladio Date of Inspection: October 4, 2002 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Bridle Path Marston Mills. MA Owner: John Alladio Date of Inspection: October 4, 2002 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Bridle Path Marston Mills. MA Owner: John Alladio Date of Inspection: October 4, 2002 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ — Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ — Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CW 15.302(3)(b)]. 5 I Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Bridle Path Marstons Mills, AM Owner: John Alladio Date of Inspection: October 4, 2002 FLOW CONDITIONS RESIDENTIAL 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: 1 Does residence have a garbage grinder(yes or no): No 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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped after inspection-per owner Was system pumped as part of the inspection(yes or no): 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 Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Apr. 25178 Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bridle Path Marstons Mills, MA Owner: John Alladio Date of Inspection: October 4, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 11" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. The owner was going to pump the system after the inspection. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bridle Path Marstons Mills, AM Owner: John Alladio Date of Inspection: October 4, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was broken down structurally. A new pit was installed(Permit#2002-454). PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bridle Path Marston Mills, MA Owner: John Alladio Date of Inspection: October 4, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'- 1000 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): One pit 04)had approximately 6"of water on the bottom. The bottom to grade was approximately 96". The cover was approximately 12". Anew pit 05)had approximately 3"ofwater on the bottom. The scum line was approximately 6"up from the bottom. There were no sign of failure. The bottom to grade was approximately 9'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition-of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bridle Path Marstons Mills, AM Owner: John A1ladio Date of Inspection: October 4, 2002 Map: 150 Parcel: 090 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot:3 Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A S V,6 O 3 a � A Q a aa.6 01-6 3 ao a7 S as s� 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bridle Path , Marston Mills, MA Owner: John Alladio Date of Inspection: October 4, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40' +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 96". Using the Barnstable topographic map and the Cape Cod Commission water contours maps, the maps were showing approximately 40'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE ITn CATION �'-/ �,,, �� i o, SEWAGE ;LAGE -Js Y\A, ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. YY1o%c&v%,L 7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) LPG_( (size) NO. OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER cc. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f`w F { >t YmB THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .....................OF......................................................................................... Appliration for Ilh4patial Works Tonotrurtion ramit Application is hereby made for a Permit to Construct or Repair (--' an Individual Sewage Disposal System at: ....? ......... . .... 3 . .......................................................................................... Location-Address or Lot No. .................................................. . ................... ....................................... owner A d..:dr e.. -—------------ .......................... �4 C Insi�fer Address M �4 Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....... .................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons........1=............... Showers Cafeteria ( ) Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow.:........_....._.__._._._......... gallons. 04 Septic Tank—Liquid capacity-,/Pkq.gallons Length................ Width.........._...._ Diameter____.___.._..... Depth............._.. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.......... sq. f t. Seepage Pit No------------7----------- Diameter-------Y.......... Depth below inlet......(............ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..................._ Depth to ground water....................._... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.__.._......__.._... Depth to ground water._._.._................. .....................................................................................:...................................................................... 0 Description of Soil.........................................................6............................................................................................................... W ....................... ................................................................................................................................................................................. ...............................................................................................................DD.................. ........................ ........................ —Answer when applicable. U Nature of Repairs or Alterations — _X-_- .. ........................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TL I li LE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ii ued by the board of health... ....... Signed_ ....... ----------/---------*------------ Date Application Approved By.............. ......... Date Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date Permit No--------- ?7;`.fs................... Issued_....................................................... Date .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4 •.................... ....................OF.......................................----......------•---...._-......................... Appliration for Disposal Murks Tanstrur#ion "permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....:..........._--.............................................................................. .............••----•---....._.........-----•••-•-----..............................------......... Location-Address or Lot No. ........................_-.....................O ner...---..............................._.... .............................................---•----............................................. Owner .-•--••-••••-•••--...-.Address a ............................................. ..................... ...............................................'- Installer Address 6 Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----•--------------------------------------•---•----......------------...........------------------....-•--•--••--•--•------- W. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------•--•-------••--•.............•--------••-•--••-•----•--•.....--.. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._..................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------•----...-•----•----............--•---.....•----._.................................................................. 0 Description of Soil......................................................................................................................................................................... U 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 TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..............•......•..---- Date ApplicationApproved By.... ]----------•------•-•-•--•--•------- ........................................-�' Date Application Disapproved for the following reasons:.............................•-•---•--•-------------------.....------------....-------------•---••--......--- -------------------------•---•------------••......-•----....-•-••-..............-----•••--•--••--••-----•....................................._.........----•-------.......------......--•--•------_..._ Permit No.........�-••�.---�X.�-...........----- Issued..........................................Date..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................`` . .......................................... Trdif irat a of Tontpfittnrr THIS ISfTO CERTIFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired ) by......... k .. .......... ........................... .11.............----•-------------................----.............. -.._..._ Y. /� q Installer at.... / l• / .... V� -fit -•---•--...----•---•-------•----...---•-•---•-•--•------• .................... has been installed in accordance with the provisions of TIT F 5 f The State Sanitary Code as described in the application for Disposal Works Construction Permit No........ � �......... dated.............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �g _� . ...........�••.t:,`:-�":a`---...OF................:�:�'?."..` � 1�(....................... No.... ... ---•-• Fn................. Disposa orko Tono#rurxion rrrnti# Permission is hereby granted.........._.........-A f! to Construct (`� or Fjgpair.( j an I divic� al Sewa g,Disposal, System ... ...... at No... 1_... itd-v C � . g!/L. Street I as shown on the application for Disposal Works Construction Permit No............. ------nD�at�d.......................................... n � . oard of Health DATE........................•-------•-•---........_.._.....••-•.....•-•-:. FORM 1255 A. M. SULKIN, INC., BOSTON LOJC ATQON � SEWAGE PERMIT NO. Lo td le P.o ill 7c-I-- V IAl E IN.STA LLER'S NAME & ADDRESS r�� cc) B U I'L D E R OR OWNER DATE PERMIT ISSUED ;?% 717 DAT E COMPl1ANCE ISSUED 7j-. 13Ar,K A�o r n / �- Tea a� LOCATION SEWAGE PERMIT NO. 01-i ale) 9/f- s--s /Ja D wJ�4 t'c s &J INSTALLER'S NAME & ADDRESS M Ile W) Chi B U 11 D E R OR OWNER '17�iU/vOS , DATE PERMIT ISSUED - 77 DATE COMPLIANCE ISSUED fit1- X-- /7 i6, Pill, '`l, No..- • ._.. ....... �� FIc$............._............... THE COMMONWEALTH OF MASSACHUSETTS BOA OF HEA TH . e .. .J-�,..W.14.....OF.......... .��- . .. .! A f1-------------------------------- App ira#ion for E apaii ai Works Tonitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy^ste at: .------. --•-• --------•-•----•----------------- ..... ...... --Lo ion-Address � �e.� C� r� �r Lot.No. ...._......... ....... .ly C�- T..._ .._ ./. f✓ ..✓�/�..... ����,r�C O er � _ _ Address ••-•--• .................................. ............................... Installer Address i 14 Type of Building Size Lot /Jk3....Sq. feet U oms._..__Dwelling—No. o Bero ......................................Expansion Attic ( ) Garbage Grinder q 04 Other—Type of Building ............................ No. of persons........:�-_.--•_--______- Showers ( ) — Cafeteria ( ) a Oth r fixtures ---------------------------------------------- W Design Flow...... .. ...............................gallons per person per day. Total da flow........ . _ _...................gallons. 44 Septic Tank—Liquid capacityiD_,09..gallons Length....... ....... Width---------------- Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching areaa7zc---------sq. ft. Seepage Pit No---_--------------- Diameter.................... Depth below inlet_................. Total leaching area..................sq. ft. z Other Distribution box Dosi to�j �, Percolation Test Results ) Performed by. -___I_.:( �_�_B._�).A........................... Date..�al_�__7. ____,?.. ... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ y a� Descri ion of Soi . f ry ' -........ $� x1 ...........-•-------------- ---------------•--------------------------------------------•-----------------.----------- W U Nature 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 iI'LU 5 of the State Sanitary ode The undersigned further agrees of to place the system in operation until a Certificate of Compliance has en i5 ed by the oa of Sig d �k ,� . -----• - .. Date Application Approved By...... - C � 1 � ... °Z •• 7" ----------------------------- - Application Disapproved for the following reasons:...---•------•.......................••••........--•-•••..............................••...Date....••...._... -••----••-•---•------------------------------------•-----------------------•--.........-•--••---.......------•-------••••-•-••••-•-••...•-•-••-••-•-••••-•---••---•-••---•--•--•----••--••••-•---.....-- -- Date PermitNo......................................................... Issued-------------------------------•- •-. ---•---•--- Date No.. •• r------ Fps............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE?N IJH. . .. -..--.0F...-1TA �Q . - (Q-.............................................. Appliratiun for Dhipaiial .18jarks Tansirurtion 11amit Application is hereby made* for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ..... .... .................I. Loon s Now„ dress R/ h f�� r_ob �o V } om rt �W I C Installer Address UType of Building Size Lot------ .__, --..Sq. feet a .Dwelling—No. of Bedrooms_._...................................Expansion�Attic ( ) Garbage Grinder /0 pi Other—Type of Building ••-__.-_•________________-- No. of persons............................ Showers ( ) — Cafeteria ( ) Q+ Ot r tures ------•------------------------- - Design Flow.._. .................................gallons per person p day. Total da#yflow__._...._ .. :, gal W ........----••-••••-_. lons. 9 Septic Tank—Liquid capacity/0_Q9_.gallons Length....- ...... Width.......:._'._..._ Diameter________________ D/e th................ Disposal Trench—No...................t'Width:................... Total Length.................... Total leaching are 4 z---------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosintaf> ` W Percolation Test Results Performed by.. ................ Q. 14.... .k..........................•........ Date: •._..___ .___ .__. ,_l Test Pit No. ---------------- per inch Depth of Test Pit.................... Depth to groundwater............;........... t% Test Pit No. 2................minutes per inch Depth of Test Pit............... Depth to ground water........................ ri _.... ..... ,f f O Descri r�of,; -- --- ..............j ' --- V .------ ---- L/ Cs� = W •••••••---••------------------------------------•-----•--•---••••-•••••••-•-•••••••--•---------•--------------•••--•••---•••••--•--••••-•••---------••-•••••-•••••••••-••......••••••---•-••-•---••..... U Nature 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 TITS 5 of the State Sanitary od The undersigned further agrees of to place the system in operation until,a Certificate of Compliance has =een issued by the'bo of Date � �'�...A Application Approved BY---•- - ----- ,. :' � ,...... ". Application Disapproved for the following reasons:............................................................................................ Date.............. ....................•--.....-------•---------•----•------------------------•----•-••.._..--•--•.......--- --------------------------------------------------------------------------- -------------- a Date Permit No. .... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BO RD OF HEALTH O ..... ........OF....R.A.k.k.1-00.410-...................... Ter#ifirate of (9outplianre T-VS 4,S1 TO CERTIF , That the Individual Sewage Disposal System constructed ( ) or Repairedby `..5�. . r%"" - -------------------------------------- /� " y} Q p�L4...... t at S[ -""_i-_ _ ...... . .Installer yJ� I(/ J ` has been installed in accordance with the provisions of T r of he State Sanitary Code as desc d in the application for Disposal Works Construction Permit No. ..... 4.............. dated--�" �. ....'". 7-----".._._..---"-- TH'E ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI` FACTORY. DATE : '�S ? Inspector.... ��.........................•-•-•---- r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ft�. . ...........................W. .......... ..... .. a '2" �No. FEE._..--.".. " �.. Dispo a1 orks Tonitr ion "permit Permission is hereby granted. _ .....O.M. ..--•••-••-••••••....•••...................••--••••••-••............-------•---•_.... to Constr ct ) r Ro ) an, LI�ndivl Sewa e Disposal.S tem ._ �+ at No. ....Pa Pt .l .L_. '_. .... � � ,�v !•`..--•••- t.1� -p ................. Street as shown on the application for Disposal Works Construction r it N ...... . Djaated.._.;L__`_-� "_........ .................................. / �� Board of Healt DATE .....:. '.... ....................••--•-•••........--- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - }A' ' r t � J� �� 7 •'4� •9, ..,, ,I I: ? S �� - '" �t� e P '• s {�i+ , ��At h�. 0.' w :i,.r.._•:y..-f� +, i^ � 4 !• - ~.'�tl�•f``(.t fib.. � .. 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Af #, t r ' r, ` r (J 7 O� ROBERfi8 INKS qc � S ! , No.221 2 G�STE� �NAtkV r ' L EGEND CA18'°.••"••••+ _e -E� EVATI,ONt' 9ne_. CERTIFIED PLOT PLUM IV19v vey r d — -- As,p i IMSTING CONTOUR -- - 0 - - L,PT 3p�-�- FIMI:SHED SPOT• ELEVATION �—]0 SHED CONTOUR 0 ?S Tt% 41-S liJlc G _. y A ROVED = ,EOARD OF, HEALTH r� DATE AGENTSCALE: 1 -'tiiF SC LE� DATE.'; o. 7 d�E ENGINEER IAfG Cry IN CLIENT 77p`� I CERTIFY THAT THE PROPOSED, E :(11TERE REGISTI±RED JOB NO. > BUILDING SHOWN ON THIS :PLAN ry; , AIL LAWDCONFORMS TO THE ZONING LAWSENEER SURVEYOR OR.BY: `�` F. BARNSTA.BLE MAS ro ,a N ld S 712 MAIN ST, 1 5p r 50 AR'A90'U1`M, MASS. NYANNI,Sf" MASS. N T� F f " -- r ! $ EE 0 Z ®ATE _ RE®. LAND. ,SURVEYOR r a /FE/7F,'ER j ao FT N,/N. n/07 jrc /VG P/T ARE MODE. T V /2"BELOPV -� /O FT. /•9%N• �". •- �� - - ---.—.'�r ::Tr�'••►OE, � '24.'O/AM ETE�' CON�'R�-T� C'OI�ER j�` BE 0MOIJ6N7 7"O 6R'AG�.Ci:✓`' EX7i?/q.. i`IEAVy CAST /RON CO iVER Sf�AL L 8E-�/SE_[� MIN. P/TCN I _ COVERS-ter/ �B�PERFT. �I IF/N ! /✓EN/AY r e _ GRADE CCU VER CLEAN .SANG ",A J=/L L LIQUID LEVEL �1 4" CAST b Z�LAYER ::.I /RUN_P/PE c /GOO va 7� hj !►'!/N. P/TG/'/L GAL. e e • °I • s • • • • • p o4 WASHED STilrE .PER /-r. S_EPT/C . TANK • • • • . • . . u a .i ' - v oD • eEFFECT/V� I�'® � • 3/�.:_ f /l., y - ''I o nre ° OEf�TH ° e . • aL - & j•. }:, m e..� • ° • ••, ® o D ,cp W.45REP STONE 1 4 0 . - t - I p' a„ ' ► • • ° o e o • e e p o y -- PRECAS T SEEPAG E IvV4-KT. ELEYAT/ONS �o e o° � • . ay• • • ° • • . P/T DR e4"o EQU!✓- /NYE/QT .4T ,BU/LD/NG 9��•n FT. _ 6 t �. /NLET SERT/C 7-,4NK 9.S. FT FT. OLAJv1__ ___� .0(SEg T�9BlJL 4TlON��. OUTLET SEPT/C TANK A,W-FT O U OF /STR/s9T/ON BOX 5-�FT- GRDUNv ,[�,�)TER TABLE . SECT/aN OUTLETDISTR/BIIT/ON BOX 94.9. FT. /NLET SEEoi4C7E CDV T _9 Z 9_FT. SEWAGE AV/S)IPOSA L S KS-r-=14 TASEJLAT/D/V L EAC)LI/IV 01/T ®ES/6N CRITERIA SCALE %¢ " _ /'_ 0,, p/ME/YSIIjAj ON $-I-FT FT. NUMBER OF BEO/?oOMS CsAReAGEO/SPOSAL UN/T__- _. SO/L LOG -' TOTA.G EST/M•4TE0 FLOvc/_ 3 3_c.G,41-,1,oAY S0/1- TEST /dt/ SO/L TESTpdt2 S'®/L TEST IV(JMBER.OF SEERAGE P/T5_ I �^ELE1! ` d`-ELFY,_ ,DATE OF SO/L TEST' _�©/1 7 17-7 S/OE LEACH/n/G PEst P/T -_7 _SQ FT. �4e- RESULTS $V17WESSED BY 6UTTUM LC�gGH/NG F'EK /�/T__L_'4.�$Q. PT. F�tRCOLAT/ON RATE / �_.•_n_ /+�/N�II/VC.N TOTAL LEACH//YG ARC-A �' SQ. FT. j F'EJ�COLAT/ON RATE lEk2 — MI/v.//NCR R=5 MVELEACNINuAREA'►_'�""�'6_SQ. FT. ! _ 3`f So'�S�r �9 6i0FAf4Sj,9 Vv:'i N ��r;• C 0 7- 3 8 1? ROBERT P. I IX .2 /7!z. S . i i a _. a a BUNIKIS. RAt/F L d' No.22162 0 EL OfaED�sE ENGI NCR/A!G GO AI9IG: 7/2 A//V Sr 33 iv0, MA/)v-5 14p 4TER -TNCOI�NTE. t�O HYANNiS MASS. SO. YARMQdJTIl�MASS. s GMOU/ti/O lri�/!TE'R A7- EL�I/ —n tea.