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Home My WebLink About0009 BURNHAM STREET - Health 9 Burnham Street Marstons Mills r A= 043-022 _� -� Commonwealth of Massachusetts pq 3-�oZ•a— �� Title 5 Official Inspection Form 3 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia t Owner Owner's Name information is required,for every Marstons Mills .,� MA 02648 08/17/2020 _ page., Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 51'r IL019 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. Rivers End Road Co � Company Address Teaticket Ma. 02536 Citylrown State Zip Code ` 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After-'conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails r 08/18/2020 Inspector's Signature Da e 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. Y t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i f Commonwealth of Massachusetts (t� Title 5 Official Inspection Form y I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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: ® 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: This 2 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding one 500 gallon leaching chamber. At the time of this inspection no visible failure criteria was found 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 �v Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 page. City/Town 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 FIND (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): I 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Burnham Street u Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form 111 I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is Marstons Mills MA 02648 08/17/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is Marstons Mills MA 02648 08/17/2020 required for every page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 plus Description: GPD 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 ears usage town water 9 ( Y 9 (gpd))� Detail: In 2019-90,000 gallons were used and in 2018-78,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �. :. p Title 5 Official Inspection Form 111? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is Marstons Mills MA 02648 08/17/2020 required for every page. CitylTown 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts p Title 5 Official Inspection Form <l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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: 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 25"feet Material of construction: i ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .......... 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 33" Scums thickness 4" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Burnham Street u� Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments condition of alarm and float switches etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. L15in.p.cloc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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: ® leaching chambers number: One ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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.): At the time of the inspection no visible failure criteria was found. 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 I . Commonwealth of Massachusetts ,t�: Title 5 Official Inspection Form !, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Burnham Street V Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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 I 1 tached on next page** "As-Built from the installer at y 1 i t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 I Assessing As-Built Cards https://townofbamstable.us/Departments/Assessing/Property_Valu... /J /TOWN OF BARNSTABLE LOCATION Syr,1l14-1 ST. SEWAGE# 20/2-3$4 VILLAGE)W,V,-SJOy S fW IU ASSESSOR'S MAP&PARCEL "-22 INSTALLER'S NAME&PHONE NO. S0�y2D-9938✓oSr /,�i�iyi�as SEPTIC TANK CAPACrrY /0 00 LEACI]VG FACn=.(type) /-.S00 6,g1 LNvi1/OE/ (size) /G SO k f�L.63 NO.OF BEDROOMS ,-L OWNER PERMIT DATE: -y'1L COMPLIANCE DATE: /2-?8-/°� 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 widen 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if my wetlands exist within 300 feet of leachhmg facilityy) Feel FURNISAID BY ISur'NrIkNi1 STrI=f-T t3-1=2g• � L3 Z s„ , `f�-3=43•G•, 9 3=-17 3 1 of 1 8/19/2020,5:05 PM Commonwealth of Massachusetts p Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 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: 11 plus feetfeet 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: augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I ti Commonwealth of Massachusetts ,p Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Burnham Street Property Address Anthony Dinoia Owner Owner's Name information is required for every Marstons Mills MA 02648 08/17/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION urnA401 SEWAGE# 20/,2-3$q x� VILLAGE /'j/Jpt'',S'IPO-5 10i11 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. el20—973? Asr,4!Oc 90.-r015 SEPTIC TANK CAPACITY /p 00 / LEACHING FACILITY:(type) /—,S'00 G,9161,yrt k (size) NO.OF BEDROOMS 2 OWNER PERMIT DATE: /2 —/� 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 leaching facility) . Feet r FURNISHED BY rJUI��'1Lli4yil STr`ri,'T' 0 ' Id"I� C Fee THE COMMONWEALTH OF MASSACHUSETTS THE in computer: ty Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLation for VsposaY-A�pstem Construction Vertu Application for a Permit to Construct( ) Repair( upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. "f3U 04, A ,LE V 1No ta'Owner's Name,Address,and Tel.No.,/ G 3 Assessor's Map/Parcel �{3 —�l.'L �X7 'p,�� lJ In taller's Namf^e�,Address,and Tel.No.,S°Og>y2G-�73 Design 's Name,Address,and Tel.No. 1 — Type of Building: // No.of Bedrooms -,";y 0 Lot Size "Z8 ►-L-&z sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min..required) z'L gpd Design flow provided Z4r"L gpd Plan Date `_4 A V f9 i ZD Number of sheets 1 Revision Date Title Star-r;L �.rTs�� A_ M��.J> t serz 1 "�i�rtLY..►l�A1(� ��►� Size of Septic Tank D ,Type of S.A.S. C gA ty ri�tr tjC jL t Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this BoEyd of Health. e © Date i Application Approved by Date r Application Disapproved by Date for the following reasons J Permit No. a `� Date Issued 51c// 00 -OS "... t' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ' Q PUBLIC HEALTH,DIVISION - TOWN OF,BARNSTABLE, MASSACHUSETTS 9pplication for MisposabApst m construction i3ernut 4 • Application for a Permit to Construct( ) Repair(Upgrade(. ) Abandon( ) El Complete System El Individual Components • Location Address or Lot No. °� f�v N R 5! / / Owner's Name,Address,and Tel.No.; , V0// I�`-� `7 I t�►o►Q r H Lu-lda � �� "� ' G• . Assessor's Map/Parcel A-3 — z.'L ' ,� f Installer's Name,Address,and Tel.No.Sa$-y ZO-q73 8 Design 's Name,Address,and Tel.No. ,IdSz'al-i 2/5°9,4,ee -; ylr ur2`L,1 Tea` %-� �5•t°L Type of Building: / D� No.of Bedrooms �y o Lot Size Zo ►-i,z sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _ 'L'L t7 gpd Design flow provided -Z 4c, L gpd . j Plan Date V4 o V. f9. -LO ►-7- Number of sheets 1 Revision Date 1 ` Title Sr...r- li S2s4 s T. 17W-VA I rL vz 01-L �►s tzt�4N aye �� \ t Size of Septic Tank c�,�( ,Type of.S.A.S. (:-,A��,�y�t, _�,,K�4-'.,A _ Description of Soil 's Gjr r... .��_ �trhC Sol t s f Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on;site sewage disposal system in accordance with the provisions of Title 5•ofthe..Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo d of Health. igne � o Date ® v Application Approved by �}� I / Date 1 ! - r � L., . . Application Disapproved by Date for the following reasons Permit No. r - 1, Date Issued i - - ------------------------V------------------------------------- - - - TI4 E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site ewage Disposal system Constructed( ) -Repaired-( Upgraded( ) Abandoned( )by a� at has been const ctedLnace with the provisions of\Title 5 and the for Disposal ystem Construction Permit No ated 1 Installer `J Designer ry N1 r #bedrooms _ r Approved design Qww gpd The issuance of this permit shall t be constru-d as a guarantee that the system will Function a desi ed. Date / Q Inspector ------------------------------------------------------------------------------------------------------------------------ ------------- No. � ?�( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal .6pstem construction permit Permission is hereby gr ted to onstruct( ) Repair(X Upgrade( ) Abandon( ) 21 System located at • and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction s b 0 corm leted within three years of the date of this permit. i? A - K:�) Date J Approved by l Dor_-: 1 s 207 s 758 12-03-2012 11 :48 Address: #9 Burnham Street,Marstons Mills,MA BARNSTABLE LAND COURT REGISTRY Parcel ID#: Barnstable Assessors Map 43 Parcel 22 , Owners Name: Michael J. DiNoia&Anthony M. DiNoia TITLE V DEED RESTRICTION This restriction is entered into on ,2012 by Michael J. DiNoia and Anthony M. DiNoia, Whereas Michael J. DiNoia and Anthony M. DiNoia are the owners of certain real estate located at#9 Burnham Street,Marston Mills,Barnstable County, Commonwealth of Massachusetts, as described in Land Court Certificate#198763 recorded at the Barnstable County Registry of Deeds(Land Court) as document#1206863, Hereinafter Referred to as the"Property", and further described as follows: Lot 3,on Land Court Plan#35186-B,on file in the Barnstable Registry of Deeds—Land Court Division. In accordance with and pursuant to an Order of the Town of Barnstable Health Department respecting the installation of a sewage disposal system,the Property located at#9 Burnham Street, shall be subject to the restriction that it shall not include more than: Two Bedrooms for the"Property"as referenced above. This restriction shall be released or modified only by an instrument executed by the TOWN OF BARNSTABLE, Board of Health and by The"Property" Owner his/her/or their successors and assigns. The consideration for this restriction is the approval of the sewage disposal system for the Property by the Town of Barnstable Health Department. COMMONWEALTH OF MASSACHUSETTS Barnstable,SS Witness our hands and seals this ; , 2012. On this day of 20 �Z ,before me,the undersigned notary blic,personally eared: and proved to me through satisfactory evidence of identification whhichich w were to be the person(s)whose name(s)are signed on the proceeding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. f BARNSTABLE COUNTY REGISTRY O \ DEEDS A TRUE COPY,ATTEST Notary P lic✓ t \``\S A-2 0 My Co ission xp' t(�(zu 1 o Ml ;u NFINSTM ILE REGISTRY OF DEEDS Town of Barnstable Regulatory Services Thomas F.Geiler,Director MAM"a I Public Health Division to y` Thomas McKean,.Director 200 Main Street, .HyannL%MA 02601 Qf me: 508-862-4644 Tax: $08-790-6304 Date: oL_o r-t Sewage Permit#`. Assessor's Map/Parcel Installer&Designer Certification Form Designer: 5T PHEN DOYLE AND A5 OClA €filer: Address; 42 GA1J't'ER13l1RYLAW ZA-5'f-F,ALMAt11" Mh-SAGHtIaEM owdrevs: TELI'fWNE'606 W-2534 �3Ji'eu as.com� "J On .J. was issued a permit to install a (date) (Installer) septic system at based on a design drawn by (a( ss ) dated (design ) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved.changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Stri -nuired)was inspected and the soils were found satisfactory. ��aF DAV►D t fie"5` v (I staller s Signature) MASON CA sNF� a ..> is esigner's Signature) q f igner's 11' PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE wI.LL .NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE.RECEIVED BY THE BARNSTABLETUBLIC HEALTH DIVISION. THANK YOU. gAofrice fo mAlesigimmrtirmation rorm.doc i Town of Barnstable Po- l U De)?artimeut of Regulatory Services I Public Health Division Date IV - Z-L XAM says. 200 Main Street,Hyannis MA 02601 Date Scheduled ,J 6 0l �l Time Fee Pd. `0 o , 00 Soil Suitability Assessment for S e Disposal Performed•By: rf r4t1 1 2 Witnessed By: S LOCATION& GENERAL INFORMATION 1..oeation Address et "(`�1,2l-t�c�.!-�'( Owner's Name ti4. !y(r LLj Address C.aKttp 1.t'�-a -t' -Ire 10 Assessor's Map/Parcel: 4r'1 --L-L- Engineer's Name G. p"L zv. NEW CONSTRUCTION REPAIR Telephone# Land Use: "419 6�'Lts t-��r. _ Slopes(%) Sulfate Stones Dlstance9 flom: Open Water Body > I ft Possible Wet Aten } c01� ft Drinking Water Well �< R Dralhage Way S fl R Property Line _ t O ft Other #t SIETCHC(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands?n proximity to holes) r_J r.a W 0 i .. l,o'( 'Yi 'F. y3 } d y► 'J • , Zor �2Z't Sfr � � I to or- � �i In Parent material(geologic) !R Depth to Bedrock Depth to Groundwater. Standing Water in Hole: AA _ Weeping from pit Face 1`�►!�e Estimated Seasonal HIgh Oroundwater L 1441' DE,TERAUNATION FOR SEASONAL HIGH WATER TABLE Method Used: co t3 Sr81tr✓.eti9�I Depth Observed standing in obs.hole: In. 'Depth to soil mottles. lu, Dclith to weeping frorn.side of obs.holed In,- Omundwater Adjustment fit. Index Well# Reading Date: Indek Well level ..., Adj.Iltbtbi, , 7 Adj.Groundwater level,, PERCOLATI.ON TEST- r `' ime. —4234 'lima.tL=. Observation Hole# Z Tints at y" t Depth of Pero 48 t� Time At G' ! Start Pre-soak Time fe? lime(9'>6 z 4 - tti�t-k6L. End Pro-soak %t L1511 i Rate MlnAnch ,i Site Suitability Assessment: Site Passed Sitp Palled: t Additional Testing Needed(Y/N) 9 Original: Public Health Dlvlslon Observation Hole Data To Be Completed on Back=------ ***If percolation test is to be conducted within 100' of wetland,you must first notify the ' Barnstable Conservation Division at least one(1)week prior to beginning. Q:XSEPTICVBRCFORM.DOC l DEEP•OBSERVAtION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil• Ater Surface(in.) (USDA) (Munsell) Mottling (Stnreturo,Stoned;Boulders. O it t% 4.001K3V .'8 � SL l o`t��2 •l-�o+-k1G o �!-r � i� 3li�-144� (✓ 1-�lJCriTl.�.eW.t, Z �(i ll �� !'llr�'�7. (,�pptir , • is , .:'!'�i� T ,. . . DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture. Soil Color) 1 !• Soil thor Surface(in.) (USDA) (Munsolq,,j r. 1,Mottling (Structure,Stones,Boulders. Cons Ste otem, 7 Z l�k'oi-11'G o �„ t'tCb • S--3 'f3 �S �o ��;.',�G t. a Ge�u-i Tt: DEEP OBSERVATION HOLE LOG Hole#. Depth ftoni Soil Horizon Soil Texture Soil Color Soil Odier' Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color moll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Flood Insurance Rate Map:Above 500 year flood boundary 'No_ 61:1 Within 500 year boundary Nil Yes ' Within 100 year flood boundary No.T_ yes_'- Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious mtiterlal exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what Is the depth of naturally occurring per lous malarial? , Certification I certify that on 3 (date)I have passed the soil evaluator examination approved by the Department of EnvIronmental Protection and that the above analysis was performed by me consistent with the required training,exp rdse and experience described In�10 CMR 15.017. Signature Datb 11-PZ•-[Z Q:tS1?PT1C\PRRCP0RM.D0C , T 9.t} CO y/ ... m Postage $ `�S MIA 0+' Certified Fee o ,. Postmark O Return Receipt.Fee Here' (Endorsement Required) 1 V�+, 1 C3 Restricted Delivery Fee r3 (Endorsement Required) O Total Postage&Fees • 7J - �.J� Ms. Sabine C. McNamara c/o Federal Home Loan Mtg Corp 5000 Plano Pkwy ;, Carrollton, Tx 75010 Certified Mail Provides:to A mailing receipt (esieeay)ZpoZ eunf'OOse wjoj Sd ® A unique Identifier for your mailpiece o A record of delivery kept by the Postal Service for two years rmliortant Reminders: Q Certified Mail may ONLY be combined with First-Class Mails or Priority Mails. 0 Certified Mail is not available for any class of international mail. p NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. O For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 38111 to the article and add applicable postage to cover the fee.Endorse mailpiece Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required.. - ,�For an additional fee, delivery may be restricted to the addressee or addressee's authorized a ent.Advise the clerk or mark the mailpiece with the endorsement"RestrictedDelivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. . IMPORTANT:Save this receipt and ppresent it.when making an Inquiry. . Internet access to delivery information is not available on mail addressed ta'APOs and FPOs." �'�' SECTIONCOMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ,Agent ■ Print your name and address on the reverse X Timothy Fridia ❑Addressee so that we can return the card to you. B. Ro% nq C. Date of Delivery ■ Attach this card to the back of the mailpiece, of on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: 'If YES,enter delivery address below: ❑No Ms. C. McNamara c/o Federal Home Loan Mtg Corp '` 5000 Plano, Pkwy 3. Service Type Carrollton, Tx 75010 ❑'certffied Mail ❑Epress Mail a 0 Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4..Restricted Delivery?(Ends Fee) ❑Ye 2. Article Number (;ranter from serviceiabeq 7006 0810 0000 3524 6826 Ps Farm 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 ++t E�iEi jE:i� j 'EiilCdi tlEEii�fii�Erf UNITED STATE6:PO�TAL Wi : E E`• i First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division 200 Main Streety Hyannis, MA .02601 r .ir Town of Barnstable Barnstable THE T°�y 1. ° Regulatory Services Department e"aMi iSARNAsS.. E, ` public Health Division m NA 9- �Q v�pT fD MA't 2007 200 Mam Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3524 6828 October 3, 2012 Ms. Sabine C. McNamara c/o Federal Home Loan Mtg Corp 5000 Plano Pkwy Carrollton, TX 75010 The septic system located at 9 Burnham Street, Centerville, MA was last inspected on 8/1//2012 by David Fletcher, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic system is in hydraulic failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the.septic system within the deadline period will result in future enforcement action. PER ORDER OF THL BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Documentl Parcel Detail http://issg12/intranet/propdata/ParcelDetail.aspx?ID=2876 _..i f r a r •t Logged In As: Parcel Detail rL;esday, October 2 2012 Parcel Lookup Parcel Info Parcel ID 043-022 I Developer LOT 3A Lo Location 9 BURNHAM STREET I Pri Frontage 168 Sec Road WAKEBY ROAD Sec I Frontage 116 village MARSTONS MILLS I Fire District C-O-MM Town sewer exists at this address No I Road Index 0198 Asbuilt Septic Scan: Interactive#. 043022 1 Map I != Owner Info Owner MCNAMARA, SABINE C I Co-owner %FEDERAL HOME LOAN MTG CORP streets 5000 PLANO PKWY I Street2 City CARROLLTON I state TX Izip 75010 Country - Land Info Acres 0.46 I use Single Fam MDL-01 ( zoning RF Nghbd 0105 Topography Above Street ( Road ,Paved utilities Public Water,Gas,Septic I Location - Construction Info Building 1 of 1 Year Roof Ext Built 1977 I Struct Gable/Hip I wall Wood Shingle Living 816 ( Roof Asph/F GIs/Cmp I AC None Area Cover Type ,,I Style Ranch Int I wall Drywall I Rooms Be 2 Bedrooms ( woK Int Bath Model Residential I Floor Carpet I Rooms 1 Full ( �� eMr. 2'a 10 Grade Average ( Type Hot Air I Rooms Total 4 Rooms 34: Stories 1 Story I Heat Gas I Found Typical Fuel ation Gross 1752 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2876 10/2/2012 3 f' I f I f �� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments Props Address Owner Own is Name information is n required for 1 1�� ►''Lt� �_,_ � Q"�� every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A When filling out - General Information forms the computer, r,use 1. Inspector: only the tab key t0 move your cursor-do not Name of Inspector `mil use the return �' 1 key. D. S �- CJ�t �� C�� rlc-jr Comp ny Name. Company Address City State Zip Code Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority inspectors Sign lure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•0"8 Title 5 r1spectionn Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prop Address Owner Owner Name information is required for every page. City/Town State Zip Code Date of Inspection B. Ce;havet n (cont.) Inspectmary:Check A,B,C,D or E/always corn ete all of Section D A) Sys : ❑ und any information which indi es that any of the failure criteria described 15.303orin310CMR 15.304 ist.Any failure criteria not evaluated are low. Com B) System Conditionally sses: ❑ one or more sy em co ponents as described in the"Conditional Pass"section need to be replaced or re aired.Th system, upon completion of the replacement or repair,as approved by the Board off, f ealth,will p ss. Check the bo or"yes", "no"or of determined"(Y, N, ND)for the following statements. If"not determined," lease explain. The septi tank is metal and over 2 years old"or the septic tank(whether metal or not)is structur y unsound,exhibits subst tial infiltration or exfiltration or tank failure is imminent.System will pa inspection if the existing tan is replaced with a complying septic tank as approved by the Boar of Health. • metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of ompliance indicating that the tank is less han 20 years old is available. ❑ Y ❑ N ❑ ND(Explain elow): t5ins•00MB Title 5 Official inspection Form:Subsurface Sewage Disposal system•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Addre s Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection B. Certificat on (cont.) B) System Co ditionally Passes(cont.): ❑ Observation o sewage backup or break out or high st is water level in the distribution box due to broken or o tructed pipe(s)or due to a broken, s led or uneven distribution box.System will pass inspection 'f(with approval of Board of Health . (Explain below): ❑ broken pl e(s)are replaced Y ❑ N ❑ ND(E p a be o ) ❑ obstruction removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution bo is leveled or repla ed ❑ Y ❑ N ❑ ND(Explain below): ❑ The system requ/inspecti m e than 4 times a year due to broken or obstructed pipe(s).The system will pass (with pproval of the Board of Health): broken pplaced ❑ Y ❑ N ❑ ND (Explain below): obstructid ❑ Y .❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board o ealth: ❑ Conditions exist which require further evaluation by a Board of Health in order to determine if the system is failing to protect public health,safety or a environment. 1. System will pass unless Board of Health determin s 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 t5ins.008 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address owner Owner's'Name information is ,,, _ &M rp h tC oZ required for ty/—..—""��S 1fLvQ every page. Ci frown State Zip Code Da a 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 p lic health, afety and environment: ❑ The system has a septic tank and soil absorption system(SAS.}'and the SAS is within 100 f t of a surface water supply or tributary to a surface water supply. ❑ he system has a septic tank and SAS and the SAS is tivbin a Zone 1 of a public water supply. ❑ The stem has a septic tank and SAS and the$ACS is within 50 feet of a private water supply well. ❑ The system has a eptic tank and SAS and the S is less than 100 feet but 50 feet or more from a private ter supply well'". Method used to determi distance: **This system passes if the well wat analysis,performed at a DEP certified laboratory,for coliform bacteria indicates absent and the ese of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that other fail a 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 clogged SAS or cesspool ❑ 2t 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'/2 day flow t5ins,09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is _,�� required for State Zip Code Date of Inspection every page. City/Town 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 e a facility with a design flow of 10,000 gpd to 15,000 gpd. For large stems,you must indicate either"yes"or`no"to of the following, in addition to the questions in ion D. Yes No ❑ ❑ the system is wit ' 40 feet-of surface drinking water supply ❑ ❑ the syst is within 200 feet of a tributary to a ace drinking water supply 101 t system is located in a nitrogen sensitive area(Interi ellhead Protection 13 Area—IWPA)or a mapped Zone II of a public water supply w If you have answered"yes"to any question in Section E the system is considered a signifi nt 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 0 shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins,008 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's ame information is f Z, required for s F S 1 CCS � every page. Citylrown 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? ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 15ins-008 Title 5 Official Inspection Form:subsurface sewage Disposal System•Page 6 of 17 Commonwealth-of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address /J 1 Owner Owner' Name information is i' ! required for Az every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence'have a garbage grinder? [] Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes,� No Laundry system inspected? es o Seasonal use? ❑ Yes.;J: No Water meter readings,if available(last 2 years usage(gpd)): �tAt Detail: Sump pump? ❑ Yes Cg No Last date of occupancy: t)eIe�� Date Commercial/industrial Flow Conditions: of Establishment: Design flow on 310 CMR 15.203): gallon r day(gpd) Basis of design flow(seats/persons . etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding t resent? ❑ Yes ❑ No Non-sanit aste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins•08P08 Title 5 official Inspection Form:Subsurtace Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Elm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _ q j?V_e_k)04st -L Property Address Owner own r•s Name information is m In required for �'�- -' �� every page. Cdyfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N Was system pumped as part of the inspection? ❑ Yes 2r 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) IT 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•09r08 Title 5 Official Inspection Form:SuWuftCe Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is _AR�U d& wL-C St ✓�� o'�� Z required for ate Zip Code Date of Inspection every page. Cltyrrown St D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: fee�- Material of construction: JoTcast iron ❑40 PVC [Iother(explain): r Distance from private water supply well or suction line: feet^' Comments(on condition of joints,venting, evidence of leakage, etc.): v� Septic Tank(locate on site plan): f -4- Depth below grade: feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene Q other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) (] Yes ❑ No Dimensions: o G ��'C_ Sludge depth: t$ns•048 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 �_ i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address a/e� �G Owner OwndYs Name information is r' Gf �� g required for d every page. City/rows State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 6 Distance from top of sludge to bottom of outlet tee or baffle T `r Scum thickness Distance from top of scum to top of outlet tee or baffle --- �.1 c Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? �� Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _ t Q l,c��irG c�' ins L 0 Cr Ai �' N rya nS 0 u7- Oct btr • Q[//gib.� ,�, Grease Tr (locate on site plan): Depth below gr e: feet Material of construc' n: concrete ❑ m I ❑fiberglas ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance fr 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 t5im,Ogg Title 5 Official Inspection Fom Suksurface Sewage oisposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prbperty dress � QP Owner owner's Name information is Imp,,ex required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holdi Tank(tank must be pumped at time of ins ction)(locate on site plan): Depth below grad : Material of construc n: ❑concrete metal ❑fib glass [] polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(conditi of alarm and floa switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.09/D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts IVTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Rfifd�'-?` %F I—, . .. Prope Address A6V121— Owner Owner's Name information is yt_ ^ Luc t Ite required for L\Ag �, (r,( rvu u_ every page. Cityfrown 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 '! 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.): s C.'2 L 42 Pump Chamber(locate on site plan): Pumps in wo ing order: Yes ❑ No Alarms in work! g order: ❑ Yes ❑ No Comments(note ndition of pump chamber,condition of p ps and appurtenances,etc.): Soil Absorption System(S (I ate on site plan, excavation not required): If SAS not located,expl n why: 15irts.09108 Title 5 official Inspection Form:Subsurface Sewage Disposal$ybtern•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Ad ss An Ir Omer owner's Name information is JL'A4J-1 required for every page. Cityfro`n n State Zip Code -bare of Inspection D. System Information (cont.) Type: leaching pits number: ❑ 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.): Cesspools(cesspool must be pumped as part of inspection)(loca n site plan): Number and configuration Depth—top of liquid to inlet i ert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groan ter inflow ❑ Yes ❑ No t5ins,008 Title 5 Official Inspection Form:subsurface sewage Disposal system•Page 13 of 17 Commonwealth of Massachusetts Title 5 Off ial Inspection Form Subsurface Sewage Di posal System Form-Not for Voluntary Assessments ,a Property Address Owner Owner's Name information is required for every page. City/Town State Zip 9&e Date of Inspection D. System Informat on (cont.) Comments(note condition of soil,signs of hydraulic ilure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of constructio Dimensions Depth of solids Comments(n a condition of soil,\signsodraulic failure, level of ponding, condition of vegetation, etc.): t5ins•0948 Title 6 Official Inspection Form:SUGsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 dcAJ ^ Prope Address Owner Owners Name information is �` � �p required for A`Rs r 6�lAl H'I r L 6S ' every page. !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 f..- V 0- 2 31 Ilk 13 , �s Z t5ins-008 Title 5 Official Inspection Forth:Subsurface Sewage 4isposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property A ress Owner Owner's Name information is it /�f1(j] C Cj required for every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope L SC kL Surface water �CS Check cellar E,-�-Shallow wells a/"c)Ah:� Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 9 -22 If checked,date of design plan reviewed: r 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: 2 r, Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5tns.p9/08 Title 5 Official Inspection Form:SuWLidaos Sewage Disposal System-Page 16 of 17 Z -7 C�x COMMONWEALTH OF'�1ASSACHUSETTS f� EYEcuuvE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION I� ONE WINTER STREET. BOSTON. MA 02108 617-292.5;00fo CP WILLIAM F.WELD �_ UDY COX y0 Governor LP ARGEO PAIL CELLGCCIiy DA SFRL'H5 Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONS FORMS v'r� y tic: S1 �T T PART A 1 � d /(3 �� n,• �.�A.CERTIFICATION 7�/'"+ ��I Property Address: �� (''� Address of Owner: L/ Date of Inspection: (If different) Name^of Inspector: so$epq I am a DEP approved system inspector pursuant to Section 15.340 of Title.5 (310 CMR 15.000) Company Name: f / r- � Mailing Address: 966 A/i—aJT u,,J 2a. l9 P/-3,L2 L AI/C C Telephone Number: ,7 k5/2-P F-0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurae and C"D'Mpiete as of the :ime of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Y/.Passes _ Conditionally Passes _ seeds Further Evaluation By the Local Approving Authority Fails t Inspector's Signature: Date— The Svstem Inspector shall submit a copy of this inspection report to the Approving Authoritv within thirty (30) days of completing Mis inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the Svstem owner shadl submit the report to the aooroeriate restonal office of:he Department of Environmental Protection. The original should be sent to the system conger and copies sent to the buyer. if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: :7ave PASSES: not found anv information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15JZ3. Any failure criteria not evaluated are indicated below. - COMMENTS: 7`6�� IV Qc- /r r Qz W,#f O aAJV C/I"eb J?/D t✓ifl ,R=aEPLd[g:t PLW- ,aiAT -r*i✓A Aaiv jQ 13aW A.,; f P s84dC 61 SYSTEM CONDITIONALLY PASSES: One or mo - -em components as described in the "Conditional Pass" section need to be repla repaired. 'he system, upon completion of the replace air, as approved by the Board of Health, will pass Indicate ves, no. or not determined (Y, N, or NDI. Describe basis on in all instancese'If"not oetermined", explain why not. The septic tank is metal, unless the owner rator has pro ' ;he system inspector with a coov of a Certificate of Comohance ,attached) indicattn a tank was installed within twen vears prior :o :he date of the inspection: or the seotic tank, wheth not metal, is cracked. structurally unsound. shows subsianttai orreexfiltration, or tank ent. The system will pass inspection !f the existing septic tank s repiaceo w:th a conior i g septic -ank as aooroved by the Board of Health. ;rev:aed 31.':S 97, Page 1 of 10 GEP:n:tie vioro V'h7e we0 nr.P,Pwww magnet state rra-s Pez SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BJ SYS CONDITIONALLY PASSES icontinued) x is due t u ` sir & d Sewa ckup or breakout or high static water level bobserved ry d in the The sysem wistribill pass inspection broke pipets) or due roken, sett h approval oe he f I or uneven distribution t • Board of Health). Descr servations: sa laced ) broken pipe( <4 ved obstruction is remo distribution box is levelled or rep a • , 'The system required pumping more than four a year due t0 broke, obstructed pipe(s). .The system will pass insoeCZion if(with approval of the Bo ealth): broken, are replaced ctbn is removed 4 ` ;Ot QUIRED BY THE BOARD OF HEALTH: C) FU ER EVALUATION IS RE Conditi exist which require further evaluation by the Board of Health in order to determine if the system is failing t otect the public heait , afety and the environment. 1) SYSTEM WILL PASS U SS BOARD OF HEALTH D� "AND THE ENVIRONMENT- WHICH OT FUN NING IN A MANNER WILL PROTECT T UBLIC HEALTH „. _ Cesspool or privy is within 50 " t'of a surface water _ feet ' ordering vegetated wetland or It r:arsh. Cesspool or privy is within 50 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL " P NDE�SLIC PUBLIC HPEALTH AND SAPLIER, IF OFE7Y AN DETERMINES HE , THAT THE SYSTEM IS FUNCTIONING'IN A MANNER THAT , ENVIRONMENT: The system has a septic tank and soil abso n system (SA d the SAS is within 100 feet to a surface water supply or _ tributary to a surface water suopl}'. supply well. _ The system 'us a septic tank and absorption system and the SAS within a Zone 1 of a public water supp well. _ The system has a septic tank soil absorption system and the SAS is in SO feet of a private water suppiv _ The system has a septic K and soil absorption system and the SAS is :ess t n 100 feet but �0 feet or more from a private water supp ell, unless a well water analysis for coiiform bacteria and latile organic compounds indicates that the well is rorn pollution from t sa: �dcility and the?` presence of.arnmcr.:a nitro, and nitrate nitrogen is equal to or less tha ppm. Method used to determine distance (app'rozimation'not liar. 3) OTHER Page 2 o: :0 travised 04/:5/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: ate of•Inspection: :r ,.DJ S TEM FAILS: You mus indicate ei;- er "Yes" or "No" as to each of the following: I h e determined that the system violates one or more of the following failure criteria as defined in 310.CMR 15. The basis for tht determination is identified below. The Board of Health should be contacted to determine what will b ecessary to correct the failur Yes No Backup o ewage into facility or system component due to an overloaded or ci ed SAS or cesspool. Discharge or po ing of effluent to the sudace of the ground or sur�a" waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the dist ution box above oude Vert due to an overloaded or cioggec SAS or cesspool. Liquid depth in cesspool is less than w invert or available volume is less than 1..,2 day flow. Required pumpine more than Imes in the t year NOT due to clogged or obstructed pipe(s). Number of times pump _ Anv portion of` Soil Absorption System, cesspool or p is,below the hieh groundwater elevation. Am., rtion of a cesspool or privy is within 100 feet of a surfac ater suppiv or tributary to a surface water supply. Anv portion of a cesspool or privy is within a Zone I of a public well: ` Anv portion of a cesspool or privy is within 50 feet of a pnvate water supply it. _ — Anv portion of a cesspool or orivv is less than 100 feet but greater than 50 feet from - private water supply well with no acceptable water ouaiity analysis. If the well has been analvzed to be acceptable. atta opy of well water analysis for coiiform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. LARG't: SYSTEM FAILS: - - - "ou indicate ettr "heYes" or"vo' as..to each of the following: t he low:;ne drrena acph tp:arge s•;,stems tn;aaatttor. to the-criteria above: The system serve facility with a design.flow of 10.000 gpd or greater (Large Syst red the system is a significant threat to public health and safety the environment because one or more of the f ing conditions exist: Yes No the system is within 400 feet urface in water supply the system in 200 feet of a tributary to a surface nking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhea rotection Area- AVPA) or a mapped Zone II of a public water supply well The owner or operator of any such system shall brine the system and faciiin• into full compiiarce we he eround%%ater treatment program requirements of 114 ,.tR 5.00 and 6.00. Please consult the iocat regional office of the Department *or er tntormauon. zay.9ed 0�/25 Page 3 of SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. Z A _ None of the system components that period. n pumped for at Large vvollumes otewater have notast two weeks and the system been introduced intothereceiving recentlylor flow rates g as part of this inspection. As built plans have been obtained and exami ed. Note ii they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. V _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. rr _ All system components, excluding the Soil Absorption System, have been located on the site. / The septic tank manholes were uncovered, opened, and the interior.of the septic tank.was.inspected for condition of bathes or tees, material of construction, dimensions,.depth. of liquid, depth of sludge, depth of.sctim. .. / The size and location of the Soil Absorption System on the site has been determined based on:-.,, . Y _ The facility owner land occupants, it d freren from owneri werreprovided.with information on the proper maintenance of Sub-Surface Disposal System. � � ��17 �� woo . Existing information. Ex. Plan at B.O.H. V _ y Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] ;rav:sed 04/:5/97) Page 4 Z= 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: V'q*& Owner: Date of Inspection: - FLOW CONDITIONS RESIbENTIAL: Design flow: e.p.dJbedroom for S.A.S. . ti, Number of bedrooms:_ Number of current residents: Garbage grinder (yes or no): I/A Laundry connected to system (yes or no):Ve Seasonal use (,yes or no):A104 :Water meter read ings• if available (last tnvo (2) ,year usage !.gpd): All Sump Pump (yes or no): ' :• m c �.: Last date of occupancv: Qit/r C*GLMMERCIAUINDUSTRIAL: Type o tablishment: Design Flow: ailons/dav Grease crap prese . ves or noi_ _ Industrial Waste Holdin_ — nk present: !ves or noi_ - Non-sanitary waste discharged, he line S system: Ives or no) Water meter readings. if available: Last date of occupancy: OTHER: (Describ Last date cupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: b P11AM144 &--&/2/1/' 131/p/L9/�6L' System pumped as par, of !nsoec:on: Ives or no: If ves, volume pumped: ealions Reason for pumping: TYPE OfAYSTEM 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if knowni and source of information: BOUT >s— /i ea ��_'t1�a�✓w�2 Sewage odors detected when arriving at the site: ,ves or no)�f :evased 041.5/9') page 5 o: 10. c t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) Property Address: s�MC Owner: Date of Inspection: l SYSTEM (SAS)-..v SOIL ABSORPTIONS _ ive methods) but may be approximated by non-intros I n if possible-, excavation not required, Y P i plan, n site P locate o p If not determined to be present, explain: / Tr U^P /f, VA-110M2 A.0 Type: leaching pits, number: *, leaching chambers, number:_ leaching galleries, number: leaching trenches, number,leneth: ... leaching fields. number, dir eniions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of rvdrauiic failure, level of ponding, condition of vegetation, etc.) �u �O CESSPOOLS to on site plan) Number an onfiguration: Depth-top of liq • to inlet invert: Depth of solids layer: Depth of scum layer._ Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be oumoed part of inspecnonr;' Comments: (note condition of soil, signs of hydraulic failure, level pondin condition of vegetation, etc.) PRIVY: _ (locate on site plan) "Dimensions: Materials of constr ion: Cet=th,of solids: ,Comments: ' condiuon.of.vegetation, etc. (note„Con uion of soil, signs of hvara , Puuc faiiure, level or onarng.: I Page B of 10 kzevised 04/25/9'. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILD G SEWER: (Locate on Ian) Depth below grade: Material of construction: _cast iro 40 _other(explain) Distance from private ware p y well or suction lin �Cnme meter . ondition of joints, venting, evidence of leakaee, etc.) SEPTIC TANK:z (locate on site plan) Depth below grader Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explainl If tank is metal, list age _ Is aee confirmed-by Certificate of Compiiance _,Yes/N-o) Dimensions: DDO ` 6�%�ir�� - oy Sludge depth: Distance from too of s)udee to bottom of outlet tee or baffle: u Scum thickness:, g Distance from top of scum to top of outlet tee or battle: ' Distance from bottom of scum to bottom of outlet tee or baffle: . How dimensions were determined: h��i� Comments: ' (recommendation for pumping, condition o�niet and outlet tees or baffles. depth of liquid !eve) in'relation to outlet invert. structutai• inteerin•, evidence of ieakage, etc.) GREASE TRAP: (locate on site plan) Depth below e: Material of constructs concrete _metal _Fiberglass _Polyethylene _othenexplain Dimensions: Scum thickness: Distance from top of scum to top of outlet oa Distance from bottom of scum to m of outlet tee or ba Date of last pumping: ....•..._............ . Comments Lrec endauon for pumping, condition of inlet•and'otiilet tees or baffles. death of liquid le relation ;o outlet invert:strucurai teorim% evidence or leakage, etc.' Page 6 of 10, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGH HOLDING TANK: (Tank must be pumped prior to, or at time, of inspectio (locate on si Ian) Depth below grade: st rete _metal _Fiberglass _Polyeth a other(explain) Material of con ruction: _c Dimensions: Capacitv: gallons Design flow: gall.onsidav- Alarm level: Alarm ori:;ag order —Yes; _ No Date of previous pumping: Comments: (condition of in ee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) M Depth of liquid level above outlet invert:_ Comments: .S/U1�'LG (note if level aPd distribution is equal, evidence of solids carn+over, evidence of leakage,hto or outfox, etc? 10 PUMP CHAMBER:_ (locate on 'e plan) Pumos in working order: (Yes or No) Alarms in working order (Yes or*401 Comments: (note condition of pump chamber, condition of pumps and a ances, etc.) I I Page 7 of 10 (revised 04/25i97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) • J b 3 FAos r f vf� 02 ddl,? f , M L S ` _ tea. J'� d0y 4460C#/,jG Rl r� 4d J'11&0V - Ta 3U- I I Page 9 of 10 } ;revised 04;=S!971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION (continued) d Property Address: Owner: Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.' Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records s , Check local excavators. installers Use USGS Data ti Describe in your own words howyou established the High Groundwater Elevation. (Must be completed) "7- fO IT �iclO 6Qod� �' #� f i Pig• :0 of :.. (revised 04/25/9') ftfal V19 _ - 19 der _ --- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F �°I Address of property y6Q��a �vv � Owner' s named *„ k` �• \i, ` , Date of Inspection ,�J��ay� : . PART A CHECKLIST :_ Check if the following have been done: K Pumping information was requested of the owner, occupant, and Board of-- �' Health. --- None of the system components have been pumped for at least two weeks - and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for sighs of sewage back-up. _ The site- was inspected for signs of breakout. _ All system components, excluding the SAS , have been located on the site . The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of .-baffles or tees, ;: material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ The. size and location of the SAS on the site has been determined based '' on existing -information or approximated by non-intrusive methods. The facility owner. and occupants, y ( if different from owner) were - provided with information on the proper maintenance of SSDS. f= V I i 1 SUBSURFACE SEWAGE DISPOSAL' SYSTEM INSPECTION: FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If re sidential number of bedrooms.. _ number:. of current residents garbage grinder,. 'yes or no .K des laundry connected to system, yes or -no seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: We.\ I iSo� V-1) SAS. Last date of occupancy j: GENERAL INFORMATION Pumping records and source of information: tV O System pumped as part of inspection, yes or no _ if yes, volume pumped 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) Other (explain) Approximate age of all components. Date installed, if known. Source of =_ information: CIA 30 Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - SYSTEM INFORMATION continued - SEPTIC TANK: S . Y (locate- on s.i e plan) - depth below -grade: - material of construction: _concrete metal FRP other(explain) - dimensions: iO )C1�!, -. sludge depth . �' distance .from top of sludge to bottom of outlet tee or baffle scum. thickness . distance from top -of- scum to top of outlet- tee or baffle z � distance from bottom of scum to bottom of outlet tee or baffle Comments: -7 (recommendation for pumping, condition of inlet and outlet. tees or baffles, depth of liquid level in relation to outlet invert,. structural integrity, evidence of leakage, recommendations for repairs, etc. ) IL- ' .. :, v_ { M DISTRIBUTION BOX: _- (locate on site plan) � !ItOc� . depth of liquid level above outlet invert Comments: (note if level and distribution is equal , evidence of solids carryover, _= e 'den e of leakage into or out of bo recommendation f repairs, etc. ) (� $ PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B i - - SYSTEM INFORMATION continued SOIL ABSORPTION .SYSTEM (SAS) :_ _ (locate on site plan, if possible; excavation not required, but may be approximated by 'non-intrusive methods) If not determined to be present, explain: _s -TYPe leaching pits and number leaching chambers and number leaching. galleries . and number leaching trenches, number, length - � leaching fields, number, dimensions overflow cesspool , number Comments: 47 (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendation's f m intenance or repairs,etAl . ) J o ._ CESSPOOLS (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 (cesspool must be pumped as part bf- inspection) Comments• (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) - I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE LISPOSAL SYSTEM: include ties to at :least two permanent" references- landmarks or -benchmarks ' YS locate all wells within 1001. q �uuo h ST, NAvveskou � rQ4N T = Low` 3 40 V S� ss - DEPTH TO GROUNDWATER f. depth to groundwater --- method-.of- determination or approximation: a - 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. 0 FAILURE CRITERIA Indicate yes, no, or not determined (Y, .N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why- not) - Backup of sewage into facility? Q0 Discharge or` ponding . of effluent to the surface' of the ground or surface waters? Q Static liquid level .in the distribution box aboveoutlet invert? _ Liquid depth in cesspool .<6" below invert� or available volume< 1/2 day flow? 6 Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? _ Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? 0 within 50 feet of a surface water? -- within 100 feet of a surface water supply or tributary to a surface water supply? within a zone I of a public well? V36 within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not. the SAS) ? within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water " supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi. , for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECtION FORM PART D CERTIFICATION . . Name of Inspector Company Name Company Addresses cz Certification Statemen � _ I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and `-i complete as of the time of inspection. The inspection was performed -and _. any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails ' to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . _ The basis for this Ma determination is provided in the FAILURE CRITERIA section of this form. Inspector ' s Signature F Date O-T 2,' S Original to system owner Copies to: Buyer (if applicable) Approving authority 9 ' I i'S a aY , c \M of \ G � V64Y � h 2� �Cl a 1^� -�A+wS1S? l Ct3^� y-re�t� C y"`•�i3� eQ�QA J `i�`Jir `t UAL." G�v Ask J / - �. � .� r t� � � _ r d � \ _ � � � .. /4 ., Y ., 3 ,. r � ..` f _ r r � � � + _ � 3 .. , �' � j r i' t f _ }, i ; 1 ! � � � . ! c i i � a i � _ _ � - � .. �..,. � .. _.�-- u VA LOCATION '� `' T� 3 SEWAGE PERMIT NO. VILLAGE INSTA LLER S NAME & ADDRESS � 3 3 3 B U I'L D E R OR OWNER r DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��--, �7-7 i '_ � � ., �,` �-r � .; R �,�'/ Y � �J � ��LL � �' � '" Ill No......... �. .. _ Fps:..� � ....... THE I COMMONWEALTH FUACtA. S,S;CHUSETTS BOAR® _ 1� r fl OF.........../ ... :.. ......................... for Disvooul Works Tonstrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .... _i#UL.-`T.-••--••..•••..................... ........._......---•--••••._.......---•-.�.a..... ....... Location-A ress or Lot No. ..... Y.) 4�.......- C-- � ........... -•------ ----fau.....WAY.. Owner Addres -�►M �s..�..1!1�,1� ---------------------------------•--- Installer Address AQ ' ........Type of Building Z Size Lot----.._.._.�.... ...Sq. feet V Dwelling—No. of Bedrooms____________________________________________Expansion Attic Garbage Grinder (Ijo) Other—Type of Building ...N.P.Ar2........ No. of persons....10NM............ Showers Cafeteria (1, ) Q' Other fixtures ---------------------------••--- . W Design Flow............................................gallons per person per day. Total daily flow........3.3Q-.......................gallons. WSeptic Tank—Liquid capacity.h.9 o.gallons Length----a........ Width-_ I......... Diameter................ Depth...4-----__-- xrll— ---- - ---ft------------- • Seepage Pit No.....2........... Diameter..... . -.: _.......... Depth below inlet ...4.-�...... Total leaching area. ..sq. ft. z Other Distribution box (J10) Dosing tank Percolation Test Results Performed by....... ?C7' _............ __ ............... Date..... 7_ ------- .___ .`. Test Pit No. 1•••--2........minutes per inch Depth of Test Pit.... Depth to ground water------ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r ..................- •-------••--. Description of Soil -4_AR.,$ ..g u� ��' ...._..�. ��1`�---------------•--�4�� 0.3 -�-�IIZS1� ��N01 w ----•---•.....1 a = ---- ------ U Nature of Repairs or Alterations—Answer when applicable....__...0 ............................................................................ ---------------------------------------------------•----•--•-------------------------...............•-•-•-•----•----•--••-----•••••-----•--•-•--•--•---•-------•--•----•---------••---•-.._.........---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with - the provisions of TITLE 5 of the State Sanitary ode—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be i sued he board of h lth. Si ned_._..: g -- -.-- ....... .77..... --- -- --- --- - -- --- -- - -- -- �I Date Application Approved By....... f- (o ---- .. ........................ --- Date Application Disapproved for the following reasons:...............................................................---------------•-----------•--------------•--- -•-----••---------------------------•--......---.....--•---------------...................----------•-......-----•---•---•---- •-----. ----••-•------•`-------------•--'......--Da......---------- te Permit No......................................................... Issued_.....11---a' ----- ........... Date 'i No..- .....::...._. FEs..... "................ ...... a THE COMMONWEALTH OF MASSACHUSETTS t.. a. BOARD O E ..........-_-- ----- F.......... !+trL ...................... Appliratilau for Dhipos al Works C omitrautinu Verutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ................................... ......................................................-- V4"r.. •---- Loca on A es r Lot No. Akre : . .. n . _ . .l ....... ..... Installer Address d Type of Building Size Lot.._........I__:.. .......Sq. feet dam• Dwelling—No. of Bedrooms.................................. .....Expansion Attic NO) Garbage Grinder (10) Other—T e of Building } _..._._ No. of persons._ ._..__.___. Showers Cafeteria QI Other fixtures -----------------------------------•---------- W Design ,Flow............................................gallons per person per day. Total daily flow........ ........................ lons. .,,9 ;.,Septic Tank—Liquid capacity h� !..gallons Length .. Width.. .___..__. Diameter_______ _______ Depth• ----- - - � --•- � Seepage PitNo. .� _-- Diameter.... ...... Depth belpw inlet...!_ .. .. Total leaching ar sq. ft. Z 'Other Di'tif•�ibution�box (PCs)`" Dosing tank '-' Percolation Test Results Performed by.. � ".. , .!^a -. ............... Date.____ + _ Test Pit No. l.....Z.......minutes per inch Depth of'`TIest`Pit .;• . ___::. Depth to ground water........ +!/ w._ Test Pit No. 2................minutes per inch Depth of..Test Pit . ..... Deptl"i to ground water.....:.:_........_. Descripti n of t► _ _...._ _f -: ' �:......3 i�-- � ..� VF WJ, ............... ---- ------------------------------------------- ................ --- .......................................... ................ UNature of Repairs or Alterations"—Answer when applicable .......... .............................................................. tie t Agreement „ The u4dersigned agrees to instal the aforedescribed Individual Sewage Disposal System in accordance with the provision ;of iIT, '``5 of the'State Sanitary i ode,— T undersigned.further agrees not to place the system in a. operation untie a Certificate of Compliance has be > sued yv he board,of he' th 'at �7 w� "J.. 'A lication Approved B ---------------------- �� ......................... PP PP Y4_ 4 t '" • :- �+. * ':.. _ Date 'Application:Disapproved for"the fpllowing reasons:................................... "'..................................... ............................................................ ._........-•--•-.,Y=" ----•--------------------------------------------------•------------ Date PermitNo -------=-----------------_._ Issued =--------------------......................... Date THE COMMQNVIFEALTH OF.MASSACHUSETTS BOARD F HEAL /wwr�w(fw� Grtifkatp o Togm liFaurr THIS IS TO CERTIFY, That-the I ividual Sewage D>, posal,.System constructed ( ) or Repaired ( ) by.. :t: .. ller has been installed in accordance "with the provisions of r 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 CONSTRUE® AS A GUARANTEE THAT THE' S 1rSTEId WILL FUNC •ION SATISFACTORY e r , DATE. �'t fl .._..::.. Inspector----- ------------------ -------0........................,._................... THE COMMONWEALTH OF MASSACHUSETTe ,.. O HEALT ..... ..0F...........BOARD r FEE N(71440 ,,W4 . Permissionis hereby granted...............=.................................................................................................. 4r to Cons ' ( Repair � ) an Inds d T Sew Disposa System ..It 44 e4_1. .... Street �� / / as shown on the application for Disposal Works Construction Perm> _______ D '/..........................................." - Board of Health � �-,}- DATE. '= . ----- r .. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS A BARNGTABLE COUNTY HEALTH DEPARTMENT BARNSTABLE, MM& OMO TtLtaaNu 362-2511 Ext. 331 Date: July 28, 1977 To: Mr. Frank Lafimena Santuit Pond Estates On the basis of a sanitary survey and a laberatory omminat ^n ovx the sample of water taken from a .....will..... .. . .. ... . . . . .. .. . . .. . . . . . . . .... located on the premises of..... .FrF .W.WTW.. .... ... .. ......... ...:. . . . . . ...... located at Lot:;.: Burnham Street; Marstons Mills ... ..... ... . ........ ... ... .. ...... .... . ..... ......... ... ..... ..... .. on. ....July.27..E-977.... . ....... .....this supply is appreved for domestic r+urposes at the -time the examination was made. If you wish further inff%rmatien regarding this supply, rlease contact us at the County Court House, Barnstable, Massachusetts (Tel: 362-2511 Ext. 331) and we will be glad to assist you in any way possible. Signed...... . .. ....'::.. .. ..... Public Health Sanitarian 3/21/77 500 3i' rr l � ' Lo T � o SEPTIC. TArdK. %,ozo 45At„ "Po LLSH C H P%rt l p t D�F.0 lie 13 A �X P . ► �9, �2 CE{Z T l F l aD p L.bT P't--..A W i fiA 04 1;It i'I� a ; 1� Vo'. +, LbCAT10tJ M fa Q STC>VIA S MI IA-S= aeT C.AL ," = 30' TyAT M z I 1 CMIZTIPI� T"AT' Tldi= 5QOv-/ .! PL-I�►►J R��EtL��.1GE t WEo►J COAAPL VS W 1TN THE 51 VE LI► E-- L o-r 3 AWCl SETVACK Ql=4UiQE,Vtc+.tZ-S 6F T►-t F3QXTEtZ �. E REGIS�T�IZED �..A.{JD SUazVcYocZS THIS IP'LAW IS LJOT eASel:;o OW A," osTE�vtL.Lt= M(asS. iEJSTQtJMEhiT SURVEti( T1{l= C3FG`5��'S SNaww APPL1CA,"-r MILLS ES.Tl�Z"t�� 1�4'aT Rr- USMO To pO'Tr--2M«I6 lOT LlWa5 I Sheer Z or f LaT .3 Y, Al ' -A7-ES ,C�G '98 � Q��PE JDDly e,4 /Al v AZO1 i�✓ ,wv SEPJ� 957S 9G' c44 q¢.5 M' - 9f,5 Gec� Ai7' TEST' c,v/j�.,51 lay�� --- 84.5 rrr, uxa��r �E+PG AE4TL- / /A/ v M1,V I416Sg Za, /T77 DES16 AJ Z)A rA I StNGGE �.4tt)/L/ - 2 BE�P.c�o�vt /✓D !-.��'B* iA/DEQ DAtL f ,c�occ.) - //D t 3 - 236 c�,QD 7,4kl e - .?3U < 156 0.56 /000 G,44_ DISPA.s,a L 101T -- 10400 c;,4 4, 425 G,r'D i .3' 5EWAGE 5Y5TEMMUDDY oY TOP FOUND. EL. 90 RiLF� VIEW FINISHED GRADE EL. 88.0'± �o INVERT EL Ill libillb 87.3'-±- RISER EL. 87.9'± 20" 20" MIN. DIA. MIN. DIA. 4"PVC IF WITH SCREW TYPE CAP INV. EL: ADD NEW PVC TEE'S WITH GAS BAFFLE FINISHED GRADE EL. 88.0'-±- WITHIN 3"OF FIN.GRADE(EACH TRENCH) INV. EL. �•--- 12.83' ---� 0� .✓�� INV. EL. BAFFLE 8G.23' R15ER I/$"TO 1/2p DOUBLE WASHED STONE (� 3"THICK OR GEOTEXTILE FABRIC `� LOCUS Liquid Level 48" iNISHED 34 :Q' . 24"f GRADE EL. $$ �I •.0'+ •LI m o b Min. G" Illll IIIII llillll/llll RISE /III/l/Nl� IIIIIIiIII 11I111111111 lII1// ` 58, ` INVERT EL. Sum INVERT EL. $.5' -� 8G.00 85.80, E ooc� 15' NO BRKjOUT.► PROPOSED LEACH TRENCH-END VIEW INV.EL. .. ;"' $2.7T EXI5TING 1000 GALLON TANK TO REMAIN G"BED OF 3/4"5TONE 84.77 --481_ _V4,_11f� ooueLewA +Eosraa� NUMBER t_oc u 5 NAAa~' PROP05ED DI5TR15UTION BOX NUMBER OF OPRECAST UNT5 NONE INSTALL ON A LEVEL, 5TA5LE AND COMPACTED 5A5E 16.5 in INSTALL ONE 500 GALLON UNIT WITH FOUR FEET OF DOUBLE WASHED STONE PROP05ED CHAMBER TRENCH AT 51DE5 AND AT EACH END . BOTTOM of TEST PIT EL.. 77. APPROXIMATE EXISTING LEACH PIT 0' �NO GROUND WATER OR REDOXAMORPHIC TO BE ABANDONED PER TITLE V FEATURES ENCOUNTERED EXIST. UTILITY POLE W-` APPKOX. WATER LINE APPROX. ELECTRIC LINE SEPTIC TANK NOTES: i V TP PRECA5T DISTRIBUTION BOX NOTES: TANK CAPACITY: IN5TALL ON A LEVEL BASE TEST PIT REQUIRED-220 @ 200%1000 GALLON TO REMAIN MINIMUM WALL THICKNESS = 2" INSTALL ON A LEVEL, 5TA13LE AND COMPACTED BA5E MINIMUM IN51DE DIM. = 12" EXIST. HYDRANT TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND OUTLET INVERT5 SHALL BE EQUAL TO EACH OTHER AND AT +86.0 EXISTING 5POT GRADE A MINIMUM OF G" ABOVE THE FLOW LINE OF THE 51=PTIC TANK AND BE ON 2" MINIMUM BELOW INLET INVERT. THE CENTERLINE OF THE 5EPTIC TANK LOCATED DIRECTLY UNDER THE THE DISTRIBUTION LINES FROM THE DI5TRIBUTION BOX 5HALL CLEAN-OUT MANHOLE. ALL HAVE EQUAL INVERT5 A5 DETERMINED BY FLOODING THE THE INLET PIPE ELEVATION 5HALL BE NO LE55 THAN 2" NOR MORE DISTRIBUTION BOX TO THE HEIGHT OF THE DI5TRIBUTION LINE AS5E55oR5 MAP 43 PARCEL 22 THAN 3" ABOVE THE INVERT ELEVATION OF THE OUTLET PIPE. INVERT AFTER ALL LINE5 HAVE BEEN 5EALED IN PLACE. THE TANK OUTLET TEE 5HALL BE EQUIPPED WITH A GA5 BAFFLE. INVERT ADJUSTMENTS SMALL BE MADE by 10ILLINS WITH DURABLE AND NONDEFORMA15LE MATERIAL PERMANENTLY REFERENCE CERT., 148G95 ANY AT GRADE COVERS 5HALL BE 5ECURED TO UNAUTHORIZED ACCE55 FASTENED TO THE LINE OR RECONSTRUCTING THE LINES REFERENCE PLAN: 35 18G5 UNTIL ALL INVERT5 ARE OF EQUAL ELEVATION. FLOOD ZONE: C FIRM PANEL 250001 0015 C WAKE Y PANEL REVISED: AUG. 19, 1985 �\ ��`�� ZONING D15TRJCT: RF f ------------- , ROAD EDGE -----� OF OVERLAY D15TRICT: WP, ZONE II 7--- ---------__, PAVE_ _ 5Y5TEM DE51GN DATA: TWO EX15TING 13EDROOM5 = 2 x I 10 CPD = 220 GPID REG. FLOW , R-1134.010 U5E ONE CHAMBER TRENCH AT 12.83'W x I G.51L x 2' EFF. DEPTH _ - 501E DATA: SIDE WALL: [I G.5+ 1 G.5+ 12.83+ 12.83] x 2.0 = 117 5F BOTTOM: 12.83 x I G.5 = 211 5F TEST DATE: I I-02- 12 38 2 x 0.74 = 242 GF'D TOTAL DE51GN FLOW PROVIDED 501L EVALUATOR: 5TEPHEN DOYLE NO GARBAGE DISPOSAL ALLOWED �° m APPROVAL DATE 03-55 -�-$$.5 -1-$$.3 WITNE55ED BY: DON DE5MARAI5 PERC RATE <2 MUNCH o r P# 13780 - LOT 3 N 20, 1 22± 5.F. / +57.5 / t 1 1 T.P. I PERC <2 WINCH r EL. 89.0' O,i "A„ 5L I OYR 3/2 PIP �J 1 L5 I \ r L-tN OF�gs GENERAL NOTES: I OYR 5/G ` +88 4 ,-__� � "i �"'- i ��`� DAVID s9 TO DEP AND 3G" (EL. 8G.0') • +87.5 1 t � B. c�N SEPTIC SYSTEM REPAIR PLAN 1 , ALL W0RKMAN5HIF AND MATERIALS SHALL CONFORMrn vJ FA E tics) ' i n ; gG MASON PREPARED FOR THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE SUBSUR G DISPOSAL OF SEWAGE, y 1 t v y tuo.toss o MED. 2.5Y 5/6 BM: TOP FOUNDATION I , �o t �, �'/STER� 00 E5 U RN "A M STREET 2. ACCE55 PORTS OVER TANK TEES 5HALL BE ACCE551BLE WITHIN G"' 5AND ELEV. 90.3' � SHED DATUM: T.O.B. Gi5± j / i ►t , MAK5TON5 MALLS, MA55ACHU5ETT5 OF FIN15HED GRADE.3. ALL COMPONENTS OF THE SANITARY SYSTEM 5HALL BE CAPABLE OF I \� // �`_`-' �_ �_,��`- ^�_ - ,� Ir DATE: NOVEMBER 8, 2012 WITHSTANDING H- 10 LOADING UNLE55 OTHER'W15E NOTED. 144" X rC • ' Lr 4. THE EXCAVATOR/CONTRACTOK 5HALL CALL "DIG SAFE" AND VERIFY THE LOCATION EL. 77.0' -I-$7.i GRANGE(DRIVE OF 51TE UTILITIES PRIOR TO ANY EXCAVATION, AND 5HALL BE RE5PON5IBLE FOR NO GROUND WATER OR ALL MATTERS RELATING TO ELECTRIC AND/OR GAS EASEMENTS. REDoxIMOR>'HiC FEATURES o�sERVED I ► *� I -1- •� 5. SEW ER PIPES SHALL BE 5CHEDULE 40 PVC. Ott DIA, UNLE55 OTHEKW15E NOTED) "' #2 � � D TO BRING COVERS TO GRADE SHALL BE �' ' t _w i r , • �' G� • 0 20' 40' G. ANY MASONRY UNITS USE {-$6.4 / w 24 "`�-w $7• r r ; o STEpHEN , ► MOR TARED IN PLACE. �� \ tilts ' • DOYLE�. �, � SLOPE OF 0.02 FT. PER FOOT. / o6'_ i.,rsTrrv� HAVE A MINIMUM SL / Tavo \ r '' A� PQ SCALE: is) = 20' 7. FINISH GRADE 5HALL �r 1 .► of � 8. EXISTING SYSTEM COMPONENTS - IF ANY- 5HALL BE ABANDONED PER T.P. I PERC <2 WINCH ,BEDROOM 1 / 1 ;�q �o • • p�'ELLlNG� r: �/ r 1 ►►�0 SU �.E �� TITLE 5 REQUIREMENTS. E�. 89.0 0„ "' m / d HALL BE RESPONSIBLE TO CONTACT DOYLE "A" I OYR 3/2 ; ' - - .. 1 W I z 9. THE EXCAVATOR/CONTRACTOR 5 5L AND ASSOCIATES 24 HOURS PRIOR TO ANY REQUIRED IN5PE CTIONS. g° ( rsT.SLAB r / �; J / + t�..• 10. ALL COMPONENTS SHALL BE MARKED WITH MAGNETIC TAPE OR "Bw 1 I i \ to t LS � ,,.... J ! �/ i \ � � PLAN RtV151ON5: COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED. I OYR z ail i 5/6 i 1 1 . WHERE WATER SERVICE 15 LOCATED CLOSER THAN 10 FEET FROM 36" (EL. 86.0'> -" _-- _ 1 o+ I SERVICE LINE 5HALL BE SLEEVED IN PVC. "Cs) _ J sr,Fp I1 r lul SEWAGE COMPONENTS, SE 1 Ll PERC @ 4& +85.8 MED. 5AND 2►" 5820 20 E 109.22 j NO. DATE REV1510N5 2.5Y 5/6 t „ r r EL. 77.a 144 I 5TEPHEN DOYLE AND ASSOCIATES NO GROUND WATER OR REDOXIMORPHIC FEATURES OBSERVED 42 CANTERBURY LANE EAST FALMOUTH, MA55ACHU5ETTS 0253G TELEPHONE: 508 540-2534 sjdsurvey@aol.com