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HomeMy WebLinkAbout0078 BRIDLE PATH - Health 78 Bridle Path Marstons Mills - - -�--- - - -- - - - A= 149 - 134 i I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION poi TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION / g /� 00 Property Address: 78 Bridal Path Marstons Mills ;7 Owner's Name: Bradford Baker/Geraldine Stokes Owner's Address: 2 7() River Bronk Dr i Ve i I?r cheste-r VT �57ti7 #'. Date of Inspection:_ 3%- / 12,0 s _- Name of inspector:(please print)• Sean Jonesco Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville. MA cr' Telephone Number: (5081 775-8776 "' U_ 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.1 am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CI11R 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Dute: �� /3 -1-*G The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HealthAw 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 scot to the system owner and copies sent to the buyer,if applicable,and the approreing authority. Notes and Comments A/t k� 0-41oz /A. ,li/fool �1i31>o0 Are- 4- sd C90e6 /6 ""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 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION(continued) Property Address: 78 Bridal Path ars ons Mills Owner.• Bradtord Baker Date of inspections 313"75z—f. L Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy hem Passes: l have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist:Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N� 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 indicatingthat the tank is less than n 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: v The system required pumping more than 4 times a year due to broken or obzAlcted pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced.- obstruction is ret wA ND explain: r Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO RM PART A CERTIFICATION(continued) Property Address: 78 Bridal Path Marstons mills Owner: Bradford Baker Date of Inspection: 3i 0e 6 C. Further Evaluation is Required by the Board of Health• ✓ " A 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 Z. 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 I 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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 Gee from pollution from that facility and the presence of ammona 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 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 78 Bridal . Path Marstons Mills Owner: Bradf ord Baker Dale of Inspection: 3� cab D. System Failure Criteria applicable to all systems: You must indicate"yes'or"no"to each of llte following for all inspections: Yes N ✓� 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 J Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number 4/ 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 Jwater supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ J 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 f et froni a private Kato supply well with no acceptable water quality analysis.(This system passes if(lie well water analysis, performed al a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the m-cll is free.from pollution from that facility and tare presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to(his form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N To be considered a large sy lem the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes'or"no"to each of the following: (Inte 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—1 WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the.system is considered a significant ducat,or answered "yes"in Section D above the large system has fatted.The u%mcr or operator of arty 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 systern owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 78 Bridal Path Marstons .Mills Owner: Bradford Baker Date of Inspection: 3 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes N� 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? J _ 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 ro r maintenance of subsurface sewage disposal systems? p 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 CUR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 78 Bridal Path Mar.stons Mills Owner: Bradford Baker Date or inspection: ' �m' 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 N of bedrooms): 330 C P-0 Number of current residents: y Does residence have a garbage grinder(yes or no): rLo Is laundry on a separate sewage system(yes or no):.,v D [if yes separate inspection required] Laundry system inspected(yes or no):-i Seasonal use:(yes or no):jJ0 Water meter readings,if available(last 2 years usage(gpd)): 2005 — 42, 000 Sump pump(yes or no):. /Jo 2004 — 27, 000 Last date of occupancy: 1.r>o�� COMMERCIAL/INDUSTRIAL �A/P.. Type of establishment: Design flow(based on 310 CUR 15.203):_ gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_,A/c7 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/ Were sewage odors detected when arriving at the site(yes or no):A ro 6 Vja c 7 of I I OFFICIAL INSPECTION F0101 —NOT FOR VOLUNTARY ASSL:SSAIL:NTS SUBSURFACE SELVAGE DISPOSAL SYS1'Eh1 INSI'ECTION F0101 PART C SYSTEM INFORMATION (continued) Property Address78 Bridal Path Marstons Mi s Owner: Bradford Baker Dale of Inspection: �pp 6 BUILDING SENVEIl(locate on site plan) DcpUI below grade: l Materials of construclior _cast iron A PVC oUler(explain): Distance from private %%alcr supply well or suction line: Comments(oil condition u(juutls,venting,evidence of Icakagc, cic.). I ®,. r✓� 2�eP .tee of SEPTIC TANK:_✓(locate on site plan) De th below a r� P gr Jc. Material of construction: ✓CUIIctcic —metal fiberglass�ol�cunylene _odrer(explain) — If tank is metal list agc:_ Is age cun(inncd b- y a t�rliGcalc of Com rliarrce certificate) 1 Oes or nu): —(attach a copy of Dimensions: Jpp� Asa 1/d4-, Sludge dcplh: g�� Distance fro,,,top of sludge Iu bununl of uutict Ice or bafllc: e Scum thickness:_0" Distance from top of scum to top of outict Icc or bank.. $�• Distance Gom bottom of scum to bottom of outict Icc or bafllc: ,e I lo1v were dimensions determined: � ,� &,&tr ,�te c"e9ree—mac Conuncnts(on pumping rccommcndaliuns, inlcl and uutict tcc or bafllc condition, sUuctwal intcpity, liquid Ics•cls aasrelat/ed to outlet uiverl,es•iJence of Icakagc, etc.): �i✓b-l_si'yejiy, -r S`r]/.i� ll GREASE TMI': /V (loca(e on site plan) Dcpdi below grade:_ Material of construct lull:_concrete—uncial fibcr�lass__pulyclltylcnc other (captain): • — -- Dinunsions: Scum Iltickncs Distance from to of scuill 10 tip of uutict Ice or bafllc:Distance Gom bottonn of scull,lu bonunt of outict Icc or —a(]Fc Dalc of Iasi punnping- — Cununenls(on pumping Ieconunendatiuns, inlet and outict (cc or ba(lle culldiliu:l, sll uctutal ittte6rity, liquid Ics cis as relaled to oullel invert,cciden(e of Icaka�e,etc.): 7 'age 8 of OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEIVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cominued) Property Address:78 Btidal Path MArstnn Mil1S Owner Dale of Inspection: '3 TIGHT or IIOLDING TANK: (tank.must be pumpeJ at time of ins action Ivcale on ' I site plan Depth below grade: Material of construction:—concrete_metal_fiberglass_yulyethylene other(explaut): Dimensions: Capacity:_ gallons Dcsign Flow: gallons/day Alarm prescnt(ycs or no): Alarm level: Alann in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switclics,ctc.): DISTIUBUTION BOX: Z (if prescnt must be opcncJ locate on site lair Depth of liquid level above outlet invert: C-)of Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage i n to or out of box,ctc.):® )V t w - C t o0 I'UAIP CIIAMBER: /—Aoucatc on site plan) Pumps in working order(yes or no):— Alarms in working order(yes or no): _ Conunents(note eoudilion of pump clranlbcr, (undilion of pumps and appurtenances,etc.): Page 9 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 Bridal Path Marstons Mills Owner: Bradford Baker1 Date of Inspection: '��,�I/gW7 6 SOIL ABSORPTION SYSTEM(SAS):looca(e on site plan,excavatiodnot required) If SAS not located explain why. T�✓ leaching pits,number:o? leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching Gelds,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): r/ t✓4s (,r.� .b'(J_��z i� wc,y /VOIMG I e-4 /IBC 61 I-IsmCthL— t *y 1 INa S �,l t,. ` �,..`�-t, � o• s�.,..� G�-�c a vv�v� �? ` �r ,Y- ba f/�n-. CESSPOOLS:Jul/ 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: /(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: 78 Bridal Path Mars nns Mills Owner: Braffn Lker Date of Inspection: 3 / a SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchrbarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 0 1 . `-TAN - ` P � y P,+,4 r A-3: (of' P+ d )3- 3N ' Ll gig, 10 Page:I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 Bridal Path Mars tons Mills ' Owner. Bradford Baker Date of Inspection:_ 13191/141--nab SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water lo/ feet Please indicate(check)all methods used to determine the high ground water elevation: f Obtained from system design plans on record-If checked,date of design plan reviewed: 83' 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:i.va S eS1�r 614 A'd h,/ Li CLC{C a err l P+ ni. P. b:C�+ f1�. I ��s' St4. ova 11 LOCH 1 SEWAGE PERMIT NO. VILLAGE 1314 i 5� NAME i ADDRESS INSTA ;I�IER`t ' L.) &F%' Ll o)PL �®'U 1 E R OR OWNER ~c' DATE R M I T ISSUED I'lk 0-DATE COMPLIANCE ISSUED L6 F 0 EZO e 10. THE COMMONWEALTH OF MASSACHUSETTS �a BOARD OF HEALTH ---. . ........... ....OF...... NS`l- 1,4 - I 1 to a Appliration for Dtrapv al Works Tongtrnrfiun jJrrmit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: I , --------------------------------------------•--- ........................-R-`......................)_R = ff II Loc tion-Address r Lot No. C.!'�L�2�l�.S- ._ L3� eS --------------------------- .... kR(�?-T-- ? Y �5..4. .................................. Owner Address W ----CCL-� -------------ka en-- i-------------------------- •---•--- '�`' ��------ Ins ller _ Address J Type of Building r I (� Size Lot.. 7�.S__4U__ _.Sq. feet Dwelling—No. of Bedrooms___....._3_______________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ...................... ..... No. of persons-_ ----_.--__._____________ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow_____-..-_-- 55_________________________---gallon per person per day. Total daily flow.._......_._._.._. � g g P P P Y Y dons. c� Septic Tank—Liquid capacity/ ..gallon Length_._.__Q...... Width._..$.______ Diameter________________ Depth....I........ xDisposal Trench—No. .................... Width_._______--..._-__- Total Length-------------------- Total leaching area__:__________-------sq. ft. Seepage Pit No---------)---------- Diameter-------- _ -------- Depth below inlet..:_..../.......... Total leaching area...w!......sq. ft. z Other Distribution box ( ) D sing tank ( )Percolation Test Results Performed ...................................... Date....6J/7IF3................ a Test Pit No. I........_._minutes peri ch Depth to ground water- Test Pit No. 2---------------- ch---Depth of Test Pit__/�E__._._.. Dep round water........................ ---------------------------------------------------------------------------------------------•-----•-•-•-•-------------•-• --------------------------•---. 0 Description of Soil --------- /ltG21 -------•------------------------------------------------------------------ ----------- V UW --------------------------- - -----------I ------ L' 'f-•-- -----------� � -------- r� '` .r` -s.------------......--------- .............. Nature of Repa s or Alterations—Answer when applicable_______________________________________________________________________________ _______________ ------ ...................... ...................... Agreement: The undersigned agrees isposal System in accordance with the provisions of iITLL 5 of the.State Sanitary Code— The undersigned further agrees not to place the system in. operation until a Certificate of Compliance has ben issued the b rd of lth. igne . --------- ApplicationApproved By....... •. •.... ---•-----•-----•-------•-----•---•--•-------------------•------•------ - ,1' �d�------------. Date Application Disapproved t following reasons---------------------------------------------------------------------------------------------------------•----- -------------------------------------------------------------.........................................------------------------------------------------------------------------------------------------ Date �:. Permit No... �/o ..F$s Flo.......1-- ---..--..... - - .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH U w ................ .............. .... ..OF.....gsL�7NSiAFJ` Apli ira inn for Di!ipwi t1 nr to Tringtrnrttnn rprutit Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal System at: ••-----------•---•......... L"•-_.�.... ------.�-�-'-"�--------------------------- ---I/-: yin �qV�� �U(-JcaVot 1,d;de ss 1 t\artS�U�S — I Its` — W C_ t__�„ �n"� �j}�YZ �•JS /'4 �j VT S ------------------------------------------------------ I staller Address Type of Building Size Lot-------- --__--_--•-_--_Sq. feet h Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.--_-_-_------- __-__--__- Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------------------------------I W Design Flow............................................gallons per person per day. Total daily flow_-__-___-__':__3 _..--__-__-__-_-__.gallons. cx Septic Tank—Liquid'capacity -gallons Length___.__ ------ Width.....%-------- Diameter---------------- Depth_:-- ........ W Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area_-_.._--••_--_-__--•sq. ft. x 3 Seepage'Pit No---------- Diameter......... ....... Depth below inlet........A........ Total leaching area...u'�......sq. ft. Z Other Distribution box ( } Dosing tank ( ) Percolation Test Results Performed by..Z'- ! `v/L ___ Date__-_G17__ � - �j a Test Pit No. 1______ '"_.__minutes per inch Depth of Test Pit... 4!2_ ____ Depth to ground water... L1. Test Pit No. 2................minutes per inch Depth of Test Pit__ ---_____.__. Depth to ground water-.._-_-_-.______--_-_--. P4 ------------------ -=---------------------------------------------------•- O Description of Soil._......:-..5151 f'r-�................� 44<<--- V ----------------------------------------------------------------------------------------••--•----------------••--•-----••--••---•--• ----------------------------------------------------------- x ---------------------------------------- ------------------ ----------------------------------------------------------------------------------------------------------------------------•---------.----- 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 T ITLE: 5 of the State Sanitary Code—' The undersigned further agrees not to place the system in operation until a Certificate of Complia has been issued by the board of health. Si e -------------•------------------------•----------------------------•--------------. = t �� - ApplicationApproved BY----•---- -------------- ............................-------•••••----------------------------- Date — Application Disapproved for the following reasons_......................................................._................................................. _ ----------•---------------------------------------------------------------------------------------------.----------------------•-----------------------•------------------•-------------•-------------- Date PermitNo--------------------------------------------------- _ Issued--------•--------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ..........................................OF..................................................................................... C�rrtif iratr of Tantphanrr ... ' T L 0, ERTI Y Th t he� ',vi u Sewage Disposal System constructed ( ) or Repaired ( ) --.... -.----..,_ --y. -------•------------------------------•---------------------------------------•--------------------••--------- - /�/ r'< 7 Installer at......-----••---------•------------------------------•------•---•------------•------•-----•-------- has been installed in accordance with the provisions of .�' ��(dffhe State Sanitary ' yLribed in the application for Disposal Works Construction Permit No----------------------------------------- dated................................................ THE ISSfI NC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED GUARANTEE THAT THE SYSTEM71 F TION SATISFACTORY. 1 DATE--- -------- - ---------------------------------------------------------- - Inspector---- - )� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t ' oE ....................................OF.---.......................................---------------. -------------.•-- - No. -• ............... ..... ----••-- FEE........................ �ta�ran- � - rka �aYt,ra�ritln rrani� t Permission ereby grated---- - . -- �� --- - - -- to Constru orep t'r �. <n Sewage Disposal System atNo.---- ••-------------- ----••--•-•--------•------•-------•---•------•----------•--....-------•--- ........ -------------------------------- Sheet _ sr�- --• as shown on the application for Disposal Works Construction Permit No------------ ______ ated......................................... oard of Health DATE-................................................... ---= FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No... r'3 Fee 1 00 .00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Migpogar *pgtem Congtruction Permit Application for a Permit to Construct( ) Repair 0c) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor' ap, Vidal Path Marstons Mills1 Brad Baker Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W E Robinson Sept Sery Type ofRidtfigrvi11e Dwelling No.of Bedrooms 3 I Lot Size sq. ft. Garbage Grinder g ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install a new D Rnx Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued hi and of ealth. //ll Signed Date Vl V g�.�c�, Application Approved by Date d�" Application Disapproved by: Date for the following reasons Permit No. Date Issued 3 .6 �./ N 100.00 No.. "�L`Ji; 1_ I 1 � �3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE; MASSACHUSETTS Yes ,application for ligpogaY *pgtem Congtruction Permit � Application for a Permit to Construct( Repair�c) Upgrade( °.) ' Abandon `O ❑ Complete System ❑Individual-Components� R Location Address q_r Lot No. Owner's Name,Address,and Tel.No Assessor' 70 /p&jdal Path Marston,.s Mills - _ Brad Baker ,.. ap. c j Installer's Name,Address,and Tel.No. _v Designer's Name,Address and Tel.No. _ W E Robinson Sept Serv . P.O. Box 1089 Type of 9mrdtnjg vi11e �,23, Dwelling No.of Bedrooms VLot Size sq.ft. Garbage Grinder g ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min:required) gpd Design flow provided gpd. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) inS$S11 a new D Box 1 Date last inspected. t, �. Agreement: y The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance•has been issued b i11% d of Health. J Signed Date Cl✓t �� Application Approved by Date Application Disapproved by: Date -for the following reasons Permit No. Q Date Issued THE COMMONWEALTH OF MASSACHUSETTS �j PX BARNSTABLE, MASSACHUSETTS A Q t~ Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( x) Upgraded ( ) Abandoned( )by W E Robinson Septic, ,k at 78 Bridal Path Marstons�Mills has been constructed in accordance (� with the provisions of Title 5 and the for Disposal System Construction Permit No. 2n'n /(9 t dated / /210 �. Installer pesigner - i #bedrooms.3 z - �. 1. pprpved design--flo�W 4_ s- , J epd The issuance o this pet,mit shall not be construed as a guarantee that theisystem'w I nction as designed. j i �. , Date I � � Ihspect©r 'v 't ———————————————————————————————————————————— x No. �O Fee 100.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS igpogoY �pgtenY Congtruction permit Permission is hereby granted to Construct ( ) Repair ( x) Upgrade ( ) Abandon ( ) System located at 78 Bridal Path Marstons Mills 4 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date /3/41/ Approved by Commonwealth of Massachusetts IVIf 1'419 13 / -�_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bridle Path Property Address =� Geraldine and Bradford Baker ------ am ----- -- ;.R Owner wner's Name information is fa required for every Marstons mills Ma 02655 9/24/2015 4.n page. City/To wn State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any-3 way. Please see completeness checklist at the end of the form. Important:When General Information — -- -filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector - DiBuono Sewer and Drain lap Company Name - - - - 8 Johns path Company Address ( /Elan S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number _....-------- --- —--—---— --... --- ---------- --------------------------------- . 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 9/28/15 In ctor's Signature Datf? 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. �o US ISms•3l13 Title 5 Official Inspection Form Subsurface Sewage Disposal System• g 1 of 1'i i T � Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bridle Path Property Address Geraldine and Bradford Baker Owner a __.. Owner s Nme information is Marstons mills Ma 02655 9/24/2015 required for every _.__.. ... .. __. ..-- - page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 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 faiiure 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 contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of two Leach pits that have only been at a level of within 32 inches of invert. 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 ol(�' 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): 15,ns•3/1 3 Tdle 5 Official inspection Form Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form .1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bridle Path Property Address Geraldine and Bradford Baker Own ee r's Name Owner _.- _....._... __.... __. information is required for every Marstons mills Ma 02655 9/24/201-. page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms 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 broker, 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 systern 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 15ms•3/13 Title 5 Official Inspeclion Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts �u`-_=----. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bridle Path is Property Address Geraldine and Bradford Baker Owner Owner's Name information is Marstons mills Ma 02655 9/24/2015 required for every _ .._... . . ._ page. City/Town 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 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: 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 4 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 1/2.day flow 151ns•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 78 Bridle Path ~c-gam Property Address Geraldine and Bradford Baker Owner Owner's Name information is required for every Marstons mills Ma 02655 9/24/2015 page. City/Town 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. ❑ ® 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 107000 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 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 78 Bridle Path Property Address Geraldine and Bradford Baker O wn e r's Name Owner —_ ------- ------- - ..._ information is Marstons mills Ma 02655 9/24/2015 required for every _.- .- -.._ . page. City/Town 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: 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? ® El available 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. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 15ms•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments j 78 Bridle Path Property Address G ...... .___. Owner Owner's Name information is required for every Marstons mills Ma 02655 9/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of two Leach pits that have only been at a level of within 32 inches of invert. Number of current residents: 2 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 Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 178 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15. 03): 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? ❑ Yes ❑ No Water meter readings, if available: l51ns-3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bridle Path 4 _ Property Address Geraldine and Bradford Baker Owner ------------ .._._.._....--- - - - Owner's Name information is Marstons mills Ma 02655 9/24/2015 required for every ---------.._...._------._--__ -- - - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: none provided Source of information: 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 ❑ 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): t5ins•3n 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts �� --- Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bridle Path Property Address Geraldine and Bradford Baker Owner's_..-..._ ..__...__.... .._ .. ... wners Name information is required for every Marstons mills Ma 02655 9/24/2015 _... ...._ _. . 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: 32 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): Depth below grade: 18 _ ... _. - feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): .System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) 1000 Gallon II If tank is metal, list age: years I Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No. 1000 Gallon Dimensions: --- Sludge depth: 3 15ms•3113 - Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _� Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bridle Path Property Address Geraldine and Bradford Baker Owner Owner's Name information is required for Ewery Ma7­1rstons mills Ma 02655 9/24/2015 --_-- .--.. .. ..__-.. _ 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 24 3 Scum thickness Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (cn pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NAfeet 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 l5ms•3113 1 ille 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 \ti= 78 Bridle Path Property Address Geraldine and Bradford Baker Owner -- Owner's Name - - information is Marstons mills Ma 02655 9/24/2015 required for every _ page. City/Town 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.): Tees are in place and levels are normal. 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 Alarm present: ❑ Yes ❑ No Alarm level: - - -- - - Alarm in working order: ❑ Yes ❑ No Date of last pumping: _ -- - Dale Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No (Sins-3/13 _ riUe 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 78 Bridle.Path Property Address Geraldine and Bradford Baker Owner Owner's Name information is required for every Marstons mills Ma 02655 9/24/2015 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 At normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of lea�age into or out of box, etc.): Distribution Bo; is level and at normal level with little signs of carry over_or decay.._ - 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not loceted, explain why: 15ins•3113 1itle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts wu� _ � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 78 Bridle Path Property Address Geraldine and Bradford Baker Owner m _ Owner's Nae information is required for every Marstons mills Ma 02655 9/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: I, ® leaching pits number: 2 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: __......... -- - -----._..... Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over and no signs of hydraulic failure. 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 15!ns•3r13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y Y 78 Bridle Path Property Address Geraldine and Bradford Baker Owner - _N.. ._.. ._.... _._ Owner s ame information is required for every _Marstons mills Ma 02655 9/24/2015 . . ... ... - 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.): No signs of ponding or hydraulic failure. 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.): 151ns-•3/13 -rille 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � . 78 Bridle Path Property Address Geraldine and Bradford Baker Owner Owner caner's_ —_ ..__............... Name information is required for every to Marsn-s. mills Ma- . 02655 9/24/2015 _... _.._.- -- _. _. - .. _ _. - ._.. 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 t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17 :sing 45-Rt"I!Cal(is 8 261 IS. 1,3 1 PM L 0 CA 110 1 Al J" S E W A G E PE EMT NO VILLAGE INSTA LL E KS NAME A ADDRESS Ld PJF' @ u 1.up E Rl"r DR Own ER U-AY iJMIT ISSUED 6DAT E C 0 M F L I A N C I 1 5 S U E RIZY'I' 1. 102 Commonwealth of Massachusetts Ul - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r _ 78 Bridle Path Property Address Geraldine and Bradford Baker — ---.. ------— ---- Owner Owner's Name information is Marstons mills Ma 02655 9/24/2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Shape ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: + ftfeet 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: - -- -- 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: Pit was empty at time of inspection auger hole to 10 ft. NGE Before filing this Inspection Report, please see Report Completeness Checklist on next page. lSins•3/13 1 ille 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 78 Bridle Path Property Address Geraldine and Bradford Baker Owner Owner's Name information is required for every Marstons mills Ma 02655 9/24/2015 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 t51ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 17 of 17 y YOU WISH TO OPEN A BUSINESS? For Your Information:, Business Certificates COST $30.00 for 4 years. A Business Certificate ON'LY"REGISTERS YOUR NAME in the Town � (WHICH YOU MUST DO BY M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form. at 200 Main St:, Hyannis. .Take.the completed form to the Town Clerk's Office, V' FI., 367 Main St., Hyannis, MA 02601(Town Mall) and get the Business Certificate that is required by law. Fill in please: DATE: ,c. aA APPLICANT'S K" YOUR.NAME: '1�C>a�E) a�li1(2 t r BUSINESS YOUR HOME ADDRESS. r °'fix'` —lY� —j � �. a�A� TELEPHONE # Ba- Home'Tele hone Number. NAME OF NEW BUSINESS ;��- �� TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES . NO Have you been given approval from the building:division? YES NO ADDRESS OF BUSINESS ;��� MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You .MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have town. the appropriate permits and licenses required to legally operate your, business in this T. 'BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. _ Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual ha e med of the mit �ui., ents th t pertain to this type of business. `� ` `MUST COWLYWITHALL R"ARMUS MATERIALS REGULATIONS Authorized Sig re** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHOR IT This individual. h ,�b�en ed of the li i r quirements that pertain to this type.of business: Authorized Signature** COMMENTS: . Date:�� /Z°f/ �� TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: �F_ s_ c ASS BUSINESS LOCATION:_-)� RAZAo\�F_ e2, tYnf S T, INVENTORY MAILING ADDRESS: sty.-:. `r TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: MWML�k EMERGENCY CONTACT TELEPHONE NUMBER: '���� -�`�`'s-��� MSDS ON SITE? TYPE OF BUSINESS: rr40c-i-T-\f-1A CD INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum _ Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils 'Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I SECTION - SEWAGE r L \ 0�11 - SEPTIC TANK - - "D" BOX - - LEACH I 1 „yam TOP OF FDN - - - - - (MSL)* .2..OF IiaTO r/z'• WASHED STONEle IN . � '__._' ly"--- ..._.-_._.--.�.__' ....._. -_..- _._. f,_.�__._`� ..__._..._ .✓r ..fir I ( c /r�' ��� r, �r ! / OUT IN- OUTIN - - _ � // `✓ '+ C7� ~� ) tw. r SEPTIC - °T i j _ \ / �\/ %ry ell ELEV. TANK Co I�( � C a �.�U/ \ r / :�y�\ 4 ��% \� _ \ ELEV. ELEV. -ELEV. .. .i� 1 / fl ° 4 � `\ X.�� Cn',-!.r•��-� �v-;:'iy�J ` �.' _�._-Co,b- '� � ~�y`l, f �._ 4 � P G`• eJ,Lo �'' zS ELEV. ELEV . 1.,-••� f (. 1•C_> I`-"_ (o.5i -__ ,.c?` �, ..� �\t�'p�y \L `�l> t> I' 81 �� /�` WAS D STONE iw' TEST HOLE LOG ,f `�'° , t TEST BYa2i?�aNVL�� J. �p.cca3`f �.1}.�. iL9X !/ �[ WITNESS ?� TEST DATE DESIGN ' BEDROOM HOUSE O �� 1 T.H. # 1 9 T.H. # 2 f .� �__,_CS -- ELEV. q�° ELEV. NO 4 7 PERC RATE MIN/IN. LDISPOSER DISPOSER \ ___ _ f '3 F�OW RATE 30 (GAL./DAY ) >, �4v� 4>'�•= n,�iA.,i..�... /�P.•r' 3C�" Cn9.o SEPTIC TANK �...z3G� ().�--)_ 4-q G c.cb•4 REQ'D SEPTIC TANK SIZE I LEACH FACILITY , `moo _ s �a7 Geara �• ,a. ra SIDE WALL $Ti / e" Z (-L.6 ) - ?>-IG,=trt G/D. 01. �t F BOTTOM �� �r `_ `?� '•� ._{ ,r� ) _ __?o_"Lc• G/D. TOTAL Zc_>1, © 1`-4 Sc�•f+ USE: -/-I-----------LEACHING —___._— ~(� WATER ENCOUNTERED 1 `—'- -- -- -'_-"` _9 X. NOTES: (UNLESS OTHERWISE NOTED) 1. DATUM (MSL)+TAKEN FROM �'. _ �t _ .....QUADRANGLE MAP 2.MUNICIPAL WATER------ �_a-----------..........--------AVAILABLE M1f� r. 3. PIPE PITCH: V4"PER FOOT ' -�1F_` 4. DESIGN LOADING FOR ALL PRE'-CAST UNITS: AASHO �-i -44 \�� Oft r\�N Rr�Jv�\ .5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. `K�� 1�� 9��. -` -DISTANCE AS CERTIFIED 6. PIPE JOINTS SHALL BE MADE WATER TIGHT + 4zi ARNE H. y� ARNE 7. CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM. OF MASS. � O.IALA i H• ,r I HEREBY CERTIFY THAT THE BUILDING STATE ENVIRONMENTAL CODE TITLE 5 C> _, Q , A SITE _ _PLAN c. CIVIL 6 48 SHOWN ON THIS PLAN IS LOCATED ON THE �µ _ No 792 f GROUND AS SHOWN HEREON&THAT IT _ LOCUS: CONFORM TO THE ZONING BY LAWS OF THE �!1iK°st'i'7h-x� t� ,it__C �iy (\�STA 13: C FIttS.SS. TOWN OF S'awaROF ' vJ WHEN CONSTRUCTED. DATE �_Ca i - +o. -C • ' 3�S'�a 4. I REF: — do6dn cape eagineefinf � �� PREPARED FOR: CIVIL ENGINEERS BOARD OF HEALTH I LAND SURVEYORS REG. LAND SURVEYOR � � CONTOURS (EXISTING) -------------- �'I�A.Ir� ✓> .4� 1 � APPROVED MA Yarmouth& Orleans,MA SCALE ' (PROPOSED)-0�-0-0- DATE -----Y DATE i