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HomeMy WebLinkAbout0137 CAMELBACK ROAD - Health 137 Camelback Road Marstons Mills A = 047 - 160 _�---- - - -- l� I E c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALM06TH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms ss7may not be altered in any way. ,/�- / 7 Imp filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not Name of Inspector - use the return _ key. COMPASS REALTY DEV CORP ? =! Company Name " "^ r� P.O. BOX 2384 Company Address ' MASHPEE MA 02649 , City/Town State w Zip Code 508-221-5003 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 0 nr---'\ kzL L,�.)LU 4/10/07 Inspectors Signat re 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. 137 cammett•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 137 cammett-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 I� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 137 cammett•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 eerypge. Cit v a !Town State Zip Code Date of Inspection Y B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ N 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: ❑ Z, 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. 137 cammett-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 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 D. Yes No , ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 137 cammett•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. Cityrrown 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 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. El 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)] 137 cammett•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I� l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 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? ❑ Yes ® No Seasonal use? Yes Z No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: N/A Date 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 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): 137 cammett•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 i 4 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: n/a Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons � How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 137 cammett•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ 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.): joints tight, yes vented, no sign of leakage. Septic Tank(locate on site plan): 1' Depth below grade: 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: 1000 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured 137 cammett-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 5. V Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. Cityrrown 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.): no need to pump, tee's intact, structurally sound, liquid level equal with outlet invert, no leakage. 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.): 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): 137 cammett•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert equal with 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.): D-box is level and distribution is equal, yes solid carryover, no signs of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 137 cammett•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 r .. a Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M0 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System SAS locate on site Ian excavation not required): p Y ( ) ( P If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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 ): soil gravel, no sign of hydraulic failure, ponding dry, no damp soil, vegetation normal. 137 cammett•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i , G Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): 137 cammett-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a Z - I)o 6 i 62 3� , Pl3- 31 133-Hy ! 137 cammett•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 137 CAMMETT ROAD Property Address C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/10/07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 70 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: town of barnstable gis You must describe how you established the high ground water elevation: town of barnstable gis topo shows ground elevation at 70' 137 cammett•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I , Town of Barnstable Health Inspector Office Hours Regulatory Services 8:00—9:30 Thomas F.Geiler,Director 3:30—4:30 * BMxxsTABM only 9� MASS. r Public Health Division �FG MAC A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 � Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: Address: 137 Cammett Road Map 078 Parcel: 045 Name: Shane & Dean Stanley Phone: 774-238-0689 2. How many bedrooms exist on your property now? 4 2a. please include a copy of your floor plans for the entire property. 1 n0 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer, skip questions 4-9 below. _. 4. Location of dwelling is INSIDE a Zone of Contribution to public — Crr� 4 . supply wells? cn 5. Is the dwelling connected to an PUBLIC WATER? ` ' c cry �- r�� r� 6. Is a disposal works construction permit on file? YES or NO 6a.If yes, how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Publi ealth Divisio no objection to bedrooms at this properqW Signed: �� D e: Inspector(Print): Q;/health/wpfiles/amnestyapp °Co cr TOE • k-5 ® � r o"Co„ - 001* � j N O lac( �fivrm Uv �� mn: N Homes J i All, J �e � raorti � L i es- Feej_ / Entered in computer: THE COMMONWEALTH OF MASSAC1il3SETTS Yes -TOWN OF BARNSTABLE., MASSACHUSETTS PUBLIC HEALTH DIVISION Application for *05aX pgem. Cou�tructiou Permit ❑Individual Components Application for a Permit to Construct(�jRepair( )Upgrade( )Abandon( ) O Complete System owner's Name,Address and Tel.No. E Lot No. 1 J HJ/ .1.1.11 �`;-e-"7 Z A4 cel �lS, ©E , d'19,17�i ddr ess and Tel.No. '(1 7' Designer's Name,Address and Tel.No. jo, 'Type of Building: Lot Size sq. ft. Garbage Grinder( ) Dwelling No.of Bedrooms Showers( Cafeteria( ) Other Type of Building No. of Persons Other Fixtures gallons per day. Calculated daily flow gallons. Design Flow Number of sheets Revision Date Plan Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of.Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. _ Date X - ' - Signed - - - — ,0.- i Date Application Approved by Application Disapproved for the following reasons Permit No. "` Date Issued J . S rya z � ',err S� s Ia��Sta. ia���F• � 1;,t a w �., «��' 1 '"55"rrk y��' >'�. f$ ;p�, e k''. I a ---_ --- ---------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( e—'Repaired ( ) Upgraded ( ) Abandoned ( ) by at /s a ( f� c i�r�r"Tv 5 ,ter,j/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Z)� Designer '4 s The issuance of this permit shallp_ot be construed as a guarantee that the system will function as designed, Date Inspector s' -- i:� ——————fir= No. �^ / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wioofsaf *p.5tem Cott5truction Permit Permission is hereby granted to Construct(L- YRepair( )upgrade ( )Abandon( ) System located at and as described in the above Application'or Disposal System Construction Permit. The applicant recognizes his/her'duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructon rriust;bF completed within three years of the date of this permit. Date: �% � �'� -�� Approved by . 1 Y IS- 05" F-'K=-+-:t' .�. b„w, , '." `$3 '' -��'^cf.�r��"� ,; "� -fr�` 1����"^ y� •..-� � 'u a �,.:,•..,. s_- ,�'"^t�T '_„""� '••.�-^a'" „" - '� "�' s Roz TOWN OF BARNSTABLE s LOCATION /4 9 ��a�s�r� r/�d� SEWAGE # 5'g x VILLAGE `Giyrsr .� �Cls ASSESSOR'S MAP &LOT a�� INSTALLER'S NAME&PHONE NO:_f'477 a3�/9 'SEPTIC TANK CAPACITY 1 LEACHING FACILITY: (type) �,a l&a i /Cs (size) 14 A 15 NO.OF BEDROOMS 4' -BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: R — /7— 99 : : Separation Distance Between the: r..;z Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.,(If any wells exist 7, Feet on site o-within 200 feet of leaching facility) � r Edge of Wetland and Leaching Facility(If any wetlands exist within 300-feet'of leaching facility)' ` Feet 7777777. t • ; - ,Furnished by-. . �'1,. ✓�� `�,,;rr�,� L J } : .F r t F � 5 i I rr B ack r - J�. ^ TOWN OF BARNSTABLE LOCATION /37 SEWAGE # � S3 VILLAGE ASSESSOR'S MAP & LOT o INSTALLER'S NAME&PHONE NO. IT41A�1015 SEPTIC TANK CAPACITY /mod LEACHING FACILTPY: (type) .3 (IPA (size) X /5 NO.OF BEDROOMS -BUILDER OR OWNER F9 rt?�' PERMITDATE: 9- 9-99 COMPLIANCE DATE: R , /7— 99 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) .'.,.,Feet Furnished by 'J�. � 0 ' • e 0 a ��h "C.6 �.� No qq Fee&� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pphratton for Oisspogar *pgtem Consgtrurtiou Verna Application fora Permit to Construct(c/jRepair( )Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. 1,1,7 /9i «l-'—'77-—RV Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address and Tel.No. L/7`7 �� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil __ _ _5.i,v e ® Nature of Repairs or Alterations(Answer when applicable)�54,PE � Spa G.+a/• 1�p� (�/li llS" °,SToo-t. 14^761.�a jai_« Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed _ Date Application Approved byALO"��g4ca Date Application Disapproved for the following reasons Permit No. Date Issued J { e . No. Fee q y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: w Yes .PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEa MASSACHUSETTS 01pprication for Mizpaal *p5tem Con5truction Permit Application for a Permit to Construct(&. epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ' Location Address or Lot No. Owner's Name,Address and Tel.No. `pjppy��n,f �i19�/IS fyl0r!/G!4 �j^.�l9�l4 Assessor's Map/Parcel b:78 _G Installer's Name,Address and Tel.No. L/7 7- 09 4f 7 p Designer's Name,Address and Tel.No. ✓os rpti O->, / ,wr.^o S Jos>;pl Oy �i�HrOS Type of Building: Dwelling No.of BedroomsAIL Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Sepfic Tank Type of S.A.S. "r Description of Soil Nature of Repairs or Alterations(Answer when applicable) ;rgs' ("0/ �rti G//ia�S Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board oj Health. Signed Date X Application Approved by o Wr1,111A Date Application Disapproved for the following reasons �~ Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, at the On-site Sewage Disposal System Constructed( 'Repaired ( )Upgraded( ) Abandoned( )by t .0 rO' at W,& has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer✓r e7c e d 11 �� t�av,r r3s Designer o v� The issuance of this permit.shall not We,cionstrued as a guarantee that the system will functi�n as d 'g�ne/'d� y� Date �� 1'I�l I!�1 Inspector .r}1r� ✓L !,�.J�li'�' --- - — = ---- ' --------------- No. Fee,/ i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Ziopooar 6potem Con!5truction Permit Permission is hereby granted to Construct('Repair( ) pgrade( )Abandon( ) System located at /3 7 if , 4� & �?9�rrsrah,S lam,//� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. f Provided:Cons . ct on /'lust completed within three years of the date of this77r/ ' y� t% Date: �l-I "l Approved by l� la-I (,'L r -°c 116M NOTICE: 'This Form Is To Be Used For the Repair Of Failed _:Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, Bso� Dc 1��NHaS , hereby certify that the application for disposal works construction permit signed by me dated $— q- 9 concerning the property located at lf;7 ������ /�� �%� meets all of the following criteria: • The failed ssrstem is connected to a residential dwelling only. There are no corr=ercW or business uses associated with the dwelling. the soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system •There are no pirivate wells within 150 feet of the proposed septic system ere is no increase in flow and/or change in use proposed A--Where are no variances requested or needed. e bottom of the proposed leaching facility will ngt be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facilitytyy will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top o1'Ground Surface Elevation(using GIS information) ✓� B) G.W.Elevation +the MAX.High G.W. Adjustment. = y DIF'FEREINCE BETWEEN A and B SIGNED : �f a DATE: (Sketch proposed plan of system on back]. q:health folds.cent d Gx�577 r` C 2 S COMMONWEALTH OF MASSACHUSETTS Z R EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION a MAP RECEIVED PARCEL : 5 LOT MAY 3 0 2003 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 137 Cammett Road Marstons Mills MA 02648 Owner's Name: Kenneth and Monica Frenza Owner's Address: Same Date of Inspection: May 19,2003 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: .5 z 0 G Z, 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 nor greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System in good condition. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 'Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 3 'Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or pri%y is within 50 feet of a surface water _ Cesspool or pri%y is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a.septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammo;iia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 'Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: f Yes No _ . X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. A Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks _X_ _ Has the system received normal flows in the previous two week period? _ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS,located on site? _X_ _ 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 ? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ 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(3)(b)] f Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):440 Number of current residents:5 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use: (yes or no):No Water meter readings,if available(last 2 years usage(gpd)): 2001-109,000 gal. 2002—125,000=320 gpd Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Last pumped 8/15/02 Source of information: Homeowner supplied documentation. Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:___gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: New leaching system compliance date 8/17/99. Were sewage odors detected when arriving at the site(yes or no): No Page 7 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 BUILDING SEWER: X (locate on site plan) Depth below grade: 2' Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line: 25' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete_metal_fiberglass,polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 8' long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tee and baffle intact,tank in good condition. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete,metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INS PECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (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.): Box set level,flow equal at both aiues. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 0 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ _X_leaching chambers,number: Three 500 gal.chambers. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): No excessive vegetation or damn soils. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) I� Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): n Page 10 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May 19,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. �1 IL o � Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Cammett Road,Marstons Mills Owner: Kenneth and Monica Frenza Date of Inspection: May.19,2003 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 25 feet. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain: USGS Cotuit quad and town G.I.S. You must describe how you established the high ground water elevation: Checked town eroundwater contour map showing water below el.35 and USGS Cotuit quadrangle Mal)showing property at or above el.60.Bottom of leaching facility 5 feet below grade leaving more than 20 feet of groundwater separation. Commonwealth of Massachusetts Executive Office of Environmental Affairs y� Department ofcri & 1s� r Environmental Protection b' William F.Weld Govemor Trudy Coxe ) Secrelery,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:r ­: j -� Address of Owner. Date of Inspection: _ d�/�f� �.�? (If different) Name of Inspector: Rock F� Ake,) -k Company Name, Address_anJ Telephone .Nu ber: :�� C .`,�L�`.�V Q• CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Ai ��•��/ Inspector's Si nature: r Date: Vr The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of i0,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ine system owner and copies sent to the buyer, if applicable and the approving zij`.orlty. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: _IL ave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND), Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of.Health. (revised 8/15/95) One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 `~, Printed on Recycled Paper I y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A '�CERTI^FICAIfTII�ON I(continued) Property Addreis-� :'1� / (aM m e k ' f Owner: ay Ll' r)eq Date of Inspection:�_ Z � r BI SYSTEM C NDITI NAL'L� PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI F kTHER 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 the public health, safety and the environment. 1) SYSTEM;WI.LL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ,WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EN1' RONMENT: the wv teni nay a septic tanK anti sell ausurpLIUll syslenl and is withm iw foci iu c sui1a Y`Qiei siiNNi) or 1rIIl to a surface water supply. The system ha- a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systen, has a septic tank and soi; absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. DI YSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) _ � A Property Address: I .J CC�.{�r�� ' , `fl.. Owner: CA� Ll � l Nu of Inspectio.f�:. -- D) SYSTEM FAILS (continued): hLI Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. / W liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. An�� portion of a cesspool or privy is within a Zone I of a public well. I!�i Any portion of a cesspool or privy is within 50 feet of a private water supply well. An'y 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: /IV/ The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water suppiv well' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:: 1l f j Owner: � C_.�,L�.�./� � ! Date of Inspection: J(/ Check if the fZpumping ollpwing have been done: 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. t he.facility or dwelling was inspected for signs of sewage back-up. �he system does not receive non-sanitary or industrial waste flow tThe site was inspected for signs of breakout. YThA,l system components, excluding the Soil Absorption System, have been located on the site. e 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. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or as proximated by non-intrusive methods. �_The facili or.,,, ' occupant:, if d:4-- ^t fro-r ov;ner' were provided with information on the proper maintenance of Sub- Surface.Disposal System. (revised 8/15/95; 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION r 11 Property Address: I Owner: � Date of Inspeca FLOW CONDITIONS RESIDENTIAL: Design flow: allons Number of bedrooms: . Number of current residents: Garbage grinder (yes or no): Laundry connected.to system yes or no): Seasonal use (yes or no): Water meter readings,,if available: —LZ Last date of occupancy: / P n'� COMMERCIAL/INDUSTRIAL- Type of establishment.- Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings; if available: Last date of occupancy:OTHER: (Describe) A16y Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)LMI If yes, volume p,imPed gallons Reason for pumping: TYPE O STEM 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) and source of information: e r� Sewage odors detected when arriving at the site: (yes or no)Al (revised 8/15/95), S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION (continued) Property Address: Owner: �a`, n Date of Insoeection: SEPTIC TANKpoll/in) (locate on site Depth below grade:� Material of construction: oncrete _metal _FRP ' other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of cutlet tee or baffle:y Scum thickness:_ it Distance from top,of scum to top of outle:. tee or baffler �� Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, condition of i t and ut t tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) � GREASE TRAP& (locate on site ,plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from t)01Inm N From In hn11�m n1 owl.t 1pe or ballle- Comments: (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, etc.) (revised 8/.5/95) 6 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) _ J I 'I Property Address: CI' _�/�Y��Y Y� I I f`''I l -.y'J I�:?Y J�..l Ls Owner: �] Date of Inspecttivlm`' CJ TIGHT OR HOLDING TANK: (locate on site plan) . Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX (locate on site plan` Depth of liquid level above outlet invert:—A—/d/wrd— Comments: !note ii ievei anu distributwi, > eyucn, e%,6.nce of;cGd: cauyu,er, evidence of leakage into or out of box, 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, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I )) II SYSTEM INFORMATION (continued) I Property �7 C YY1 m t°;f- l'- I`'lI � ILI , � t. Owner: �/)'`' Date of Inspection SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excav tion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching:pits, number: leaching chambers, number:_ leaching galleries, number: leaching:trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydrauliq failur , level of ponding, condition of vegetation,etc.) L 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 groundv.ate�: inflow(cesspool must be pumped as part of inspection) Comments: (note:condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: / v (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.) (revised 8/25/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 rr SYSTEM INFORMATION (continued) Property Address: �I �. �(Y� 1�... PPH . !`'I�Z.V":��o n j �—.1 � Owner: w- L Date of InspecNo SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I_ � l �I DEPTH TO GROUNDWATER � Depth to groundwater:_ �feet method of determination or approximation:- ` a ram( ter w� v P` ` t f y'✓�7 (revised 8/15/95) 9 7-Y PARCEL ASSESSOR'S MAP NO. l A'T1ON SEWAGE PERMIT No. VILLAGE INST LLER'S NAME A ADDRESS e U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ,� � ��:; F. - .. .,;� , -_ ,. � o t :,; . , . �/ �� � �\\ � £ ~.� \ .. /// ,�� f a r� ` � �� � I �__��.�� �"�".CsB �� n w �_ � J", �'_. ��,�c�ti1,8���t s o•�/ /mac- -- - I 1 T-- No..-/ I Fps.. ...:................ THE COMMONWEALTH OF MASSACHUSETTS BOARD F H EA 6� �- F Appliratinn for Disposal Vorks Tontitrnrtiun Vrranit Application is hereby made four-aL Permit to Construct ( ) or epair ( ) an Individual Sewage Disposal _A............. ------------------------------ Loc Addr a Lot No. Address W Installer Address d Type of Buildings Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms______.._____________________Expansion Attic ( ) Garbage Grinder ( ) W Other—Type of Building No. of persons............................. Showers — Cafeteria a' Other fixtures ------------------------------------------------------ W Design Flow------------------------ ......... allons per person per day. Total daily flow---------- ._______gallons.W Septic Tank•-t-Liquid capacity/ allons Length................ Width---------------- Diameter---------------- Depth__.__-_______--- x Disposal Trench—Po. .................... Width.__..__________ tal L ��h_��. �.,,_.''.II-. Total leaching area--------------------sq. ft. Seepage Pit No.... Diameter- 'll e�e in"n et'_""`S'-- Total leaching area__e. _Q._` q. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water___--_--___-_---____---. 44 Test Pit No. 2................minutes per inch Depth of Test Pi .................. Depth to ground water------------------------ ........-•--••-- ................... ....................................................................................... - -- --------- ODescription of Soil------------ ---- --- ....... •-•-• •. •--•-•......•-• -----`--------------------------------------- ---------------------------------------- U ••••...•----•--•---•-------------------------------•----•--•---••-••-•-••-•--•---•--•--------•-•--•-•--•-•-••••-••-•-----•---------•----•------•-••-••-•••-•----------------•----------------•--------- W --------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ............................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— Th undersigned furt grees not to place the system in operation until a Certificate of Compliance has b n t sued he of h th. Si ------ •--------- --• ...... ------ Da ---------- Application Approved BY --• •-••. ---- -- .*����---t-®,�--.�--- Date Application Disapproved for the following yea o s------------------------------------------------------------------- --------------------------------------------- -•-••--•••-•--•-••••••--------••---•-•-•-••----••--•---------•-•••---•------••---••••--•--•--------------I.....••-----_...••--••-----•--••-•-•-•-----•-•-•------------------------------------------•--•- Date Permit No. ......................................................... Issued..... ...DV /' 4 '••««••••••••••••••••••••� •••••••••••••THE COMMONWEALTH•OF MASSACHUSETTS•.•• ` •• �-sue•••••••• BOARD QF HEALTH L.................OF.... ...'... .. . ....... .................... ATrrtif HI IS TO TI That the'ItLdividual Sewage Disposal System constructed ( ) or Repaired ( ) by. . ............... --- . --------=-----•---------------_------...-------------------------------------- I t ller at......... F --- ---- ------- ( 1� 'YS� has been installed in accordance with the provisions of Article XI of The State Sanitary Clod s de cribed in the application for Disposal Works Construction Permit No.............. .. ............... dated.-_�J �... .._ -3........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RIDE® A A GUARA TEE THAT TIME SYSTEM WILL FIDNC ION SATISFACTORY. DATE , d--r/= ^.._.� Inspector-------' � r ,N6......................... FEi@............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD RIF HEALTH ....................... .................OF.... ------------- Appliration for DifiVotial 10orkii Towitrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syste spy S�-, -- - --------- ............ L7t n-Addr 7 Lot Z'' ------------ --------------------------------- N w Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms__....._..........---____________________Expansion Attic Garbage Grinder -1 P4 Other—Type of Building ............................ No. of persons-_------_-__-_._-_____-____- Showers Cafeteria Otherfixtures .................................................................................................................... *_'�;2- ------------------------- ,e Design Flow........................... ... ___gallons gallons per person per day. Total daily flow_....._._. k 0' -------------gallons. 1:4 Septic Tank Liquid capacity/--,//!d`6allons Length................ Width__...__.._.___. Diameter________--_-_--- Depth_____-_--___-_-. x Disposal Trench No. ..................... ."'idth. �n - -------- Total leaching area---------------------sq. ft. D3. ...W iameterl '✓...41 11�piri A4 i' et. .............. Total leaching area._3 I _,fotal L Ll t Seepage Pit No.... .............. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date------------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit__............._____ Depth to ground water_____________________-_. fs, Test Pit No. 2................minutes per inch Depth of Test Pi ,.................. Depth to ground water------------------------ P4 ....... ........................................................................ -------------------------------- Description of Soil----________ ................. 0 /-/------------Y----- - ----------------- -- ................................................ -------------------------------------- .......................................................................................... .................................................;---------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------- ----------- ------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned fur r agrees not to place the system in f I operation until a Certificate of Compliance has been issued b/�iLe bo-;ffd 0 117 S1i 9 d........ . D..../ X.:.....I.................. ....................... X Da %8i ...Application Approved By-___---� ...... '.e4 -Z< ...... ..... ................. Date Application Disapproved for the following reaso :................................................................................................................ A ....................................................................................................................................................................................................... Date Permit No......................................................... Issued.:--/. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF...... ..................... HIS is TO �RfTl� Tprtifiratr of Tontlifitturr Xf/That the Individual Sewage Disposal System constructed or Repaired "'V�.......... w by.1 *--..I../_�.................................................................................. V at. . ...... ............t 4------- .. ..........................------ has been installed in accordance with the provisions of Article I. The State Sanitary Code..eas- de cribed in the ,�d e application for Disposal Works Construction Permit No...._._.__AY?.................. dated ------------- 61 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ......"ZL7- Inspector---------. .................................................. ................... THE COMMONWEALTH. OF MASSACHUSETTS BOARD OF, HEALTH 041f, OF.......... ................ No.../7/.....' ..... FEE.2 ' ---------------- Permission'.�s,hereby granted "ren'.----4................................... to Construct")( :V�) or Repair n .1,ndividu l...,fS ewage I)i, teem lyVe-by ............... -----------------------------4) Street as shown on the appli2ation for Disposal Works Construction Pe i N ........._ Dated___I Ile.......... . ------------------ .......... Board of Health;=.. DATE------------ ,- _V -I -1 ----------------------- FORM 1255 POBBS & WARREN, ,y-_. PUBL1,SHERS, I x TOWN OF B STABLE LOCATION I sI 64 SEWAGE# VILLAGE&STCKS ASSESSOR'S1MAP.&PARCEL INSTALLER'S NAME&PHONE NO. n SEPTIC TANK CAPACITY OS bO LEACHING FACILITY:(type)Q a4t-W d4YW0 (size) o NO.OF BEDROOMS OWNER PERMIT DATE: 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 FURNISHED BY TXJ o A3 �.3 �, Commonwealth of Massachusetts s Title 5 Official Inspection Form ,�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 rp 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. A. Inspector Information 641411C, Shawn Mcelroy Name of Inspector - Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty 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 9-11-19 Apeet6i's Signature Date / The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of(Massachusetts ' Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1-) System P..as§es: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass" 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" rY, 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 7 3� Title 5 Official Inspection Form 0) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts ' 3� Title 5 Official Inspection Form II wa LICi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .- 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town 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 P 9 g 4 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ _ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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 C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat or answered "yes"to an question in Section CA above the large system has failed. The Y any 9 Y 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? I ® ❑ Wasthe 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 p Y 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 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y ".7 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry or. a separate sewage system? (Include laundry system inspection ❑ Yes ® No information ii this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 9-2019 Last date of occupancy: Date Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town 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: Owner--pumped 2yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: New leach field t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I;i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy . ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2017 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form w. i Y'ICbi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 18"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: 1000 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 2611 Scum thickness 1" - Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments fri 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 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 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd 'G.%'•�l.TS l� Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes, ❑ No* Alarms in work.ng order: ❑ Yes ❑ No* Comments (none 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: 4-infiltrator Ic6 chambers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ le-aching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26i2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Ali i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field in good working order and empty at inspection with no sign of back-up. 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 f Commonwealth of Massachusetts 3, Title 5 Official Inspection Form it C�'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Camelback Rd T, Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .4 L `3 "d 3 6 13 cP 3 t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �i !�� 9a A i�t Subsurface sewage Disposal System Form -Not for Voluntary Assessments p Y rY 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 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: Original design plans show no groundwater at 12'. 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 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Colt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a 137 Camelback Rd Property Address Barbara Murphy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-11-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t, t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 y , TOWN OF BARNSTABLE LOCATION �� Cr ,�\�cck SEWAGE #, add-- —C)Cj (p � VILLAGE \`g ASSESSOR'S MAP&PARCEL 0 4-4- — ROO ��M,� INSTALLER'S NAME&PHONE NO. rQCrV194-*A SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 5— l.C � (size) }rt as X a NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: �{ — (0 ^ 1 �— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility fi 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) N Feet FURNISHED BY r FF ' ' ti 0 In i r eN No. C7 /��� Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWWOF BARNSTABLE, MASSACHUSETTS Yes appliLation for !Disposal *pstpm (Construttiun Permit Application for a Permit to Construct( ) Repair X `Upgrade,( ) Abandon( ) ❑Complete System IR Individual Components Location Address or Lot No. l3 It CC i"e1 iae cbe(Z,4 Owner's Name,Address,and Tel.No. to ,M'i 1�5 -1 o a C,%_a-s s —,_XxS; Assessor's Map/Parcel 0y Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. cc e't­� S` Coziv � fi06-a:g ' - 5 aci "'Ci' - Cve Type of Building: Dwelling No.of Bedrooms Lot Size ,;20, (�X0 sq.ft. Garbage Grinder(tihA Other Type of Building a No.of Persons `T Showers(V/ Cafeteria(✓� Other Fixtures k--A cw 2Q,9 G. M t, S i 5>jk ear„ Design Flow(min.required) 3 gpd Design flow provided .3 3 , 3(a gpd Plan Date �31 I Number of sheets Revision Date 1 Title a C Size of Septic Tank I5+ 1 ,ooc Type of S.A.S. LC 42C Description of Soil Nature of Repairs or Alterations(Answer when applicable) (J 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 Envir e Co e and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H th. Si d Date - Application Approved by Date Application Disapproved by Date for the following reasons Permit No. C7``�I :_,�n O p Date Issued " No. �/ ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION —TOWN-OF BARNSTABLE, MASSACHUSETTS Yes 01pplitatlon for aisposal 6pstrm ConStrUttl.on Verinit Application for a Permit to Construct( ) Repair(X�4UVg°ade��( ) Abandon( ) El Complete System ®'Individual Components Location Address or Lot No. t3 Ce +e.l h�c1c 2 H. Owner's Name,Address,and Tel.No. h1.M*11\S Assessor's Map/Parcel py Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size -}20 , p;,0 sq.ft. Garbage Grinder(rJ�A Other Type of Building �_No.of Persons 4 Showers(✓S Cafeteria Other Fixtures L.<--,30. Design Flow(min.required) 330 gpd Design flow provided 3 q 3 , 3(o gpd Plan Date Number of sheets Revision Date Title -h o SPC\ J-o C y S U Caj-P Size of Septic Tank ex t 5 7 1 ,c)oc Type of S.A.S. q- Cc (, CL1=r•-,�aer� la-�u o 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 Envir e 1,Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date S f Application Approved by Date / Application Disapproved by Date for the following reasons " i Permit No._ r0-0 t,j Date Issued ----------------------------------------------------------------------------------- -------------------- --------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifitate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by //�++ SAIL^ at ` '�- 4 rrn.P has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No-A17-Ct1P dated -3 lc)Lc 11/- Installer Designer u #bedrooms Approved design flow{ , gpd The issuance of this permit shall Jno/b/be co trued as a guarantee that the syst m will c io designed- Date `7/g /� Inspector r --------------------------------------. ------- --- ------------------- -7 � -------------------------Fee------------------- No. / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem (tolCBtrUttion i3erinit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) y ` � �\L�G C�. �C\' 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 must be complethd within/hree years of the date of this permit! Date �C� / Approved by , c Town of Barnstable Regulatory Services * Richard V. Scali,Interim Director * snnivsTnaLE, MASS. Public Health Division i°rEe MA+° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 5 'I Sewage Permit# .26 IT Assessor's Map\Parcel d 1��o Designer: C',. Installer: Address: �• O.6?�r,X 5 Address: 1-`),�0, box 1 S� �4Sir,nee , KA o-X,fl,"� t""�US hc;�ee. sUA 6D-U4(- On 3 a13 11 was issued a permit to install a (date) (installer) septic system at 3 - 0 .\bGck- based on a design drawn by ( (address) �1 dated 312:6 (designer) I 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. Strip out (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. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the I\A approval letters (if applicable) A ler's Signa a X' (bt lgner's Signatu (Affix Designer's :iarp Isere) .4- PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable P# ' Departinent of Regulatory Services i F Public Health Division Date Meal. 1'639. 200 Main Street,Hyannis MA 02601 • rErl Date Scheduled Time � d""� _.. Fee Pd. � � •. t.. Soil Suitability Assessment for Sewagre, Dispos l Performed•$y° Witnessed tnessed By:_ fin/ �"` ✓r LOCATION&.GENERAL INF'ORMA.TION Location Address ii jX- Owner's Name AddressGY� Assessor's Map/Parcel: QL{ Engineer's Name7 • r NEW CONSTRUC77ON REPAIR Telephone# 7 -4 419 c. t ` Land Use � 1 C 2(��-��C�(i,� Slopes(96)- 9Q Surface Stones /� _ Distances flum: Open Water Body `"-Ir'`- - Q Possible Wot Area 1�' ft Drinking Water Wall /- 1 i /� Dralhage Way s A Property Una ft Other {( S'IMTCHt(Street name,dimensions of lot,exact locations of test holes&Para tests,looato wetlands-in proximity to holes) ; • I i c c-o* ems. Parent material(geologic) Depth to pedrook Depth to Oroundwater. Standing Water in Hole:_ It . Weeping from Pit Raca Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL'HIGII WATER TA LE Method Used: 0 1 A- Dc th Observed sta ding in obs.hole: Ip, Depth to sell mottles., In.- . Do�th to weeping from side of obs.hole: In, Groundwater Adjustment I Pt. index Well-# Reading Date: Index Wall lmval Adj,.faotbr„�„_Adj,graundwater•LeVel,,,_ __. . . . PERCOLATION TEST Date Observation Hole# Time at 4" l`( 1\ tI ' • Depth of Para t�® too. Time at 6" 'D'' 1 ____TI Start Pro-soak Time @ 'Clmo(9"41) End Presoak 1.1 tic) Rate Mla./lnoh Site,Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) • I I Original: Public Health Division Observation Hole Data To Be Completed on Back---b•G ***If percolation test Is to be conducted within 100r of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPBRCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Sall Horizon Soil Texture Shcl Color Sall. Other Surface(in.) (USDA) .(Munsell) Mottling (Stnucture,Stoney;Boulders. • tsietency.96'Oravoll SL LP e i - 1 DEEP OBSERVATION HOLE LOG Hole# Depth from Sall Horizon Sall Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ty 3 �. DEEP OBSERVATION HOLE LOG Holm# Depth from Soil Horizon Soil Texture Sall Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Bloats,Boulders.. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Sall Texture Sall Color Boll Other Surface(in.) (URDA) (Munsell) Mottling (Structure,S(opea;Boulders, Consistency. O[GY11) Flood Insurance Rate Man: Above 500 year flood boundary No— Yes f! Within 500 year boundary No Yes Within 100 year flood boundary No.,� Yea Depth of Naturally occurrine Pervious Ma erW. Does at least four feet of naturally occurring pervious,material exist in all areas observed thrpughout the area proposed for the soil absorption system? 5 tl 1� n if not,what is the depth of naturally occurring pervious materlal? Certification I Ce t n _ .�GCp (date)I have passed the soil evaluator examination.approved by the Department of Environmental rotection and that the above analysis was performed by me consistent with . the required training,a or a fence described In 10 CUR 15.017. Signature 1 Date QASAPTiC%PflACPORM.DOC Commonwealth of Massachusetts Simi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'r- ( rasa Owner Owner's Name t ,is � o amy 1n i` 02 %required (01 f y every page. Cdy/Town State Zlp Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important A. General Information When filling out Q,�-*7 —/H forms on the v computer.use 1. Inspector: only the tab key to move your cursor-do not o use the return � k ��j��.p Company Name tuC e LMA Lf� . Company Ad ress Ma AA Ill ' /Town State Zip Code 'relephone Number license Number B. Certification ` '' I certify that I have personally inspected the sewage disposal system at this address and thatsthe - : 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=6f Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the local Approving Authority Off, o� Qlnsgpector' ignature 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. t5insp,dDc.08M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P rty Address 7c� LI Owner Owners Namerequired for c 02f6 N ll'1. /©( (y. every page. City/town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) S tem Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ or more system components as described in the"Conditional Pass"section need to be repla or repaired.The system, upon completion of the replacement or repair, as approved by the Board. ealth,will pass. Answer yes, no or n determined(Y, N, ND)in the❑for the following statements. If"not determined,°please exp in. ❑ The septic tank is metal a over 20 years old*or the septic tank( ether metal or not)is structurally unsound,exhibit bstantial infiftration or exfiftratio r tank failure is imminent. System will pass inspection if th existing tank is replaced wi a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection i ' is st urally sound, not leaking and if a Certificate of Compliance indicating that the tank is less n 20 years old is available. ND Explain: ❑ Observation of ewage backup or break out or high static water level in the distribution box due I broken o structed pipe(s)or due to a broken, settled or uneven distribution box; System will pass ins ion if(with approval of Board of Health): broken pipe(s)are replaced ❑ obstruction is removed t5insp.doc.pgfpg Title 5 Official Inspection Form:Subsurface Sewep Disposal System•Pepe 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 31 ���6..bC�_I✓L Property Address rA(�-� owner Owner's Name A Q T� ` 'CO ( l 0 information is required for t(V�cu-S�0�S /y VAS }n�(V\� 02(oL k every page. City own state Zip Code Date of Inspection B. Certification (cont.) 8) System Conditionally Passes(cont.): distribution box is leveled or replaced ND Exp%in: ❑ The system requi pumping more than 4 times a year due to broken r obstructed pipe(s).The system will pass in ion if(with approval of the Board of Health)- ❑ broken pipes are replaced ❑ obstruction is are ved ND Explain: C) Further Evaluation is Required by Board of Health: ❑ Conditions exist which require furt r ev luation by the Board of Health in order to determine if the system is failing to protect public heal ,safety or the environment. 1. System will pass unles rd of Hea , determines in accordance with 310 CMR 15.303(1)(b)that the sys m is not function g in a manner which will protect public health, safety and the environ ant: ❑ Cesspool o rivy is within 50 feet of a su ce water ❑ CesspO or privy is within 50 feet of a border g vegetated wetland or a salt marsh 2. System 11 fall unless the Board of Health(and P Iic Water Supplier,if any) detemnin that the system Is functioning In a manner hat protects the public health, safety a d environment: ❑ The system has a septic tank and soil absorption syst (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a su water supply. ❑ The system has a septic tank and SAS and the SAS is in a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is Wthi 50 feet of a private water supply well. t5insp.doc-011oB Title 5 016dal Inspection Form:Subsurface 7 Disposal System•Pape 3 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1- `l Cr,`cy\6\0C c1'z— U . Property Addrpss Owner Owner's Name r information is - 1 V `l ���0 O d o required for every page. CityRown State Zip Code Date of Itispection B. Certification (cont.) C) urther Evaluation Is Required by the Board of Health (cunt.): ❑ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee r mo om a private water supply well**. Method used t eternine distance: This system passes if the 11 water analysis, pert ed at a DEP certified laboratory,for coliforrn bacteria indicates absent and th resence of am nia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o failur aria 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 Inspection$: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ d 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 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. t5insp.doc•08= Title 5 Official Inspection Forth:Subsurface Sewspe Disposal System•Pape 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 C�rnel;�c`ct� � Property Address owner Cl C�a Ownefs Name information is ►( required for V—� . = \R� S " � 0q,101 Q 1 every page. Cityf row n State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ d 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. ❑ L�! 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 fft. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E► Large Systems: To be considered a large system the system must serve a facility with a eslgn flow of 10,000 gpd to 15,000 gpd. For la r systems,you must indicate either"yes'or"no"to each of the followin ' addition to the questions Section D. Yes No ❑ ❑ the stem is within 400 feet-of-ai-surface drinking water supply ❑ ❑ the system' itK 2' 00 feet of a tributary to a surface drinking water supply ❑ ❑ the s m is I in a nitrogen sensitive area(Interim Wellhead Protection a-IWPA)or a m ed Zone II of a public water supply well If you have a erect"yes'to any question in S i E the system is considered a significant threat, or ans "yes"in Section D above the large syste as failed.The owner or operator of any large system considered a significant threat under Section E or 'led under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o should contact the appropriate regional office of the Department. 0 t5lnsp.doc•0846 Title 5 Ofgdal Inspectlon Fof n:Subsurface Sewage U stem•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 131 cc\-me,0o id Property Address Ct6d(- Owner OwnWs Nae information is required for )m ,m�,� ti % of lot 16-7 -r— every page. city/rown 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? ❑ L� Have large volumes of water been introduced to the system recently or as part of this inspection? ly ❑ 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-08W T Ie 5 Ofiidal Inspection Form:Subsurfsoe Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments roperty Address C 1ac)( Owner Owner's Name AKA, Q information Is required for t 1 \\S KA, 0� 1� oy I C) every page. City/rown State Zip Code Date of inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �33 Number of current residents: Does residence have a garbage grinder? ❑ Yes EJ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes C No Laundry system inspected? ❑ Yes IS/ No Seasonaluse? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes Q' No Last date of occupancy: p to M( Co�mmerciaUlndustrial Flow Conditions: Type bf Establishment: Design flow(based orl-31,0 CMR 15.203): Gallons per day(gpd)— Basis of design flow(seat s/persons/sq:ftetc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? / ❑ Yes ❑ No Non-sanitary waste discharged,to'the/Title 5 system? Yes ❑ No Water meter readings ' available: Last date of upancy/use: Date Other escribe): t5inap.doc•Oa= Tide 5 Otrimi Inspechon Form:Subsurface Sewage Disposal System•Pape 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments PropeftAddr Owner Owners Nameinforrnabon is Q required for XOH 0110 every page. City/town State Zip Code Date of inspection D. System Information (cont.) General Information Pumping Records: 1 Source of information: Was system pumped as part of the inspection? ❑ Yes [�] No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: (� Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes E� No t5lnsp.doc-011106 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 8 of 15 a( Massachusetts Commonwe th of M ssac efts mrw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L 3Z CauN-e:\ Property Address A CA' Owner Owners Name c information is required.fir M'•V�L�\`S A�A- C 2-W% a d©( (m every page. c4frown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: �]cast iron d40 PVC ❑other(explain): Distance from private water supply well or suction line: feet �� Comments(on condition of joints,venting,evidence of leaka e, etc.): naWCA, vJ Zvi Aft wr tuc O ��, Septic Tank(locate on site plan): Depth below grade: tee Material of constriction: concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is meta,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -----------------------------------•-------------------------------------------------------------------------------------- 1 Dimensions: CA \- ti Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle ` Scum thickness - '}�- —`�Zi► Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle �Z-(3 How were dimensions determined? cob ea t5insp.doc•0801 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Pape 9 of 75 Commonwealth of Massachusetts BERNE Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _�-�-I C c"M6 Property Address C1aOwner Owle?s Name �� ir►forrriation is required for every page. C' Rown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, 1' uid levels as related to outlet invert,evidence of leakage,etc.): Grease Trap( to on site plan): Depth below grade: /feweMaterial of construction: ❑concrete ❑me ❑fiberglassother(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet r baffle Distance from bottom of scum to bo m of outle ee or baffle Date of last pumping: Date Comments(on pumping r mendations, inlet and ou t tee or baffle condition, structural integrity, liquid levels as related to let invert, evidence of leakag etc.): Tight or Hold g Tank(tank must be pumped at time of inspection) sate on site plan): Depth bel grade: Mat I of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene other(explain): t5insp.doc•08= Title 5 OfBdel Inspection Form:Subsurface Sewage Disposal System•Pape 10 or 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P(r Address Owner Owner's Name aInformation� r V.VM.�\-'A MAz 010 <3 Cq(0 l 0 7 every page. CRy town State Zip Code Date of Inspecdon D. System Information (cont.) T t or Holding Tank(cont.) Dimens Capacity: gallons Design Flow: gain per Alarm present: es ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Comments(condition of ala nd float switches,etc.): *Attzcopyof current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): �ez QNS ryo ��G S ©� CL�m-ef' A'f oo Pum Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in workin ❑ Yes—`❑ No t5insp.doc•08M Title 5 Oftel Inspection Fonn:Subsurface Sewage Disposal System•Page 11 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form . UIVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments A?o C<:z�\Ke C tncz. c- (,Z c3 _ Property Address CA c��L Owner Oswnnees Na'm^e(� f p/� required forte `1 V\< U v \1��`S lvlf'1`_ C)2&S C- (.®k 10"I every page. Cityfrown State Zip Code Date�spection D. System Information (cont.) 7m7(note condition of pump chamber, condition of pumps and appurtenances,etc. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: [� leaching pits number. (OK 1X z° � ❑ 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.): t5ft"Aoc•08108 Title 5 OlAcial Inspection Foam:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P�r-o^perty Address Owner Owner's Ninklmation Is ame required ror every page. C8yrrown State Zip Code Date&Insp6don D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Num rand configuration Depth—to of liquid to inlet invert Depth of solids I er Depth of scum layer Dimensions of cesspool Materials of construction X Indication of groundwater inflow � ❑ Yes ❑ No i Comments(note condition of soil, signs o draul,c'failure, level of ponding, condition of vegetation, etc.): f Privy(locate on site plan): Materials of constru 'on: Dimensions Depth of so Commen (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-08M Title 5 01Ndal Inspection Fonn:Subsurface Sewspe Disposal System-Pepe 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments E rw`��bc-QL Owner Owners NameInforrnation is f every page. clty/rown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �l c`" a Io i. C� 3 i So (::>`` 3Z-- 3(:b16 15insp•doc•08= Title 5 Dfflaal Inspection Form:Subsurface Sewape Disposal System•Pape 14 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ( \a Owner Owner's Name information is required for �l ` `yNi-L �A n(� �� O o� I n ,M\ W-�� ` every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ` Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: 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: tYou�� __ must describe how you established the high ground water elevation: Del to C)" op '� tO l�F t`V� IN i r(�e� UQ -\Pb Cox \rd S v� alf--eD'- t 0�c l l5insp.doc-08M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 15 % ! TOWN OF BARNSTABLE L CATIO . - N- SEWAGE VILLAGE ASSESSOR'S, MAP & LOT INSTALLER'S NAME.Cz PHONE NO. /Jr / r SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 12L,(sizeL Id 0 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER. OR OWNER , ��, s DATE PERMIT ISSUED: . DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No • f If J Q TOWN OF BARN TABLE LV ATION j� � -� G� \� SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL �r°�.. ". NAME&PHONE NO. `- e SEPTIC TANK CAPACITY ` P 0 QA A LEACHING FACILITY:(type) !P\1k_ (size) 00-0c NO.OF BEDROOMS OWNER PERMIT DATE: 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 FURNISHED BY O � �2-Sp�$,�� 3`" 3Sl�ir IB3-- 5(�6 TOWN OF BARNSTABLE 1.01�:ATION �t,¢ 7 „/,(T��/ �rf SEWAGE # � � VILLAGE / , f ASSESSOR'S MAP & LOT INSTALLER'S NAME 6i PHONE NO. �y��.���jr e��j��� � 77e-Z7026 SEPTIC TANK CAPACITY �� d LEACHING FACILITY:(type) (size) !d c d NO. OF BEDROOMS —7 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r � 1 ., 1 /� i' � � � nn� � Y _ �� �i �� �-�� ` � .� °�� .. � � �� �� THY"OF EAhLi�TS L . LOCAMON :13 t, asEssolz�s ivW&L SEMC TANK CAPACITY q.a /. LE ,CITO p%Ca.TI"Y': (type) C���(� e✓5 (sixv) -�.�c�',�fya�. NO`.OF13SDRt']Qks JBUJLDS9 OR trB1iA!l�T1A'1'1r. . C{�A�i'1�«�►1'iC;E D� �S�epnratiori�Dr�t�e Bctvreen Dior M�xlmum dju�t�tlCnauttdWu6v Table t6dii 96tt6m6fUaa hing.N ;dity �'lvate''�'at�r supply V,/esli;,sn�d L�e�chla�pact#aty'.�ees�y c�n!!s cxtst �: a0.eltcs oc wltbu �.Qp feet of lunehirt fac Fos I i�cyf'Wetlaarl and LeacbingGiliey([ wny wetlands exist ,*-twil 300 m -'f I" hing.fucllitY? ro F �a D i 3 4 o a 7 p.3 22/C� No.., y�r1-:.✓S2_/_.. Fizz..... THE COMMONWEALTH OF MASSACHUSETTS o BOARD OF HEALTH I _ TO N OF BARNSTABLE Ii tion for Dig osai Works Tonstrudiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal 14o ll-�-L'System at: /I Lo ton-Addre,5s or Lot No. 1/ �Ei(!!t/ P__V f!9/L..._ SY(1 �'?G'- --------------------- -------._... / ---•- - /� ntisrir�sG�iO. ,t ..a �.vt�.: �.. ��.gT �fs-��ress---Sa� �✓! ?ou7H c ...••-------•---•••• _........_._ -------------- Installer Address Type of Buildi�g`- Size Lot___9a.A ---Sq. feet V Dwelling-KNo. of Bedrooms.___.._.._____________________________Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons____________________________ Showers Cafeteria W Other fixtures --------------- -------------- - W Design Flow......_—?!_.............................gallons per person per day. Total daily flow____._ U___..__.______.______._.___._gallons. 9 Septic Tank—Liquid'capacity_/00.gallons Length................ Width................ Diameter---------------- Depth................ xDisposal Trench—No.ZO8_A_________ Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No---------------_---- Diameter............._...... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box (A ) Dosing t ( ) . Z Percolation Test Results Performed by-_; R ?ti__. ___________________ Date...................... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ODescription of Soil_..._ ... 2 ---------------•----•--•-----•-=------------------------------------------- - - x W -----------------------------------------------=---------------------------------------------------------------------------------------------------------------=--------------------------------•------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... -•------------------•-----------------------------------....------------------------•--._..._...-•------•--....----•---------------------------------------------....--••--------------......_..--..---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co s been issued by the board health. 1 Signed ... 9- `v �cr� a1 ... ............. Date....-9----------' Application Approved By .......... ---------F ll - Date Application Disapproved for the following reasons- ---------------------------------.......................... ----------------....... ........................ --....................................-. ...--...........................----.. Date Permit No. .----------� — --- ----------------- Issued -------.........................-------................. Date q No:�.. _:. 1�..t Fps.... ��......... THE COMMONWEALTHOF�MASSACHUSETTS e v S BOARD OF HEALTH t �c TOWN// OF;BARNSTABLE (/✓`y ,�L� lit/ '~ AvAirtt#tnn for Ili-qVustti M arks Tomitrnr#inn 11amit 4p U�V Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --... ......._- ._......... ..... ........... &/��A� ----..__........... -•-••....•---------•---..............---•------•-----.............-----------------•......_.---••- ••• Lo Non-Address or Lot No. E�V.vi1 ��.9it _ro'a C ,V C U P.:------.-.. ------••--•-•------------- -------•---••------•-------.-------------"...•---.----•---•-•-- j/ Oyvner ddress //AEU PzA.,sTite_1,e_ ! S.r�� _ .�5�G?E•oT iT/! .2 GYiys .v ._ ...... ---••-------------------••--- Installer Address dType of Buildin�g�" Size Lot.... d�_� �...Sq. feet U Dwelling, N o. of Bedrooms..........�5...•....-•..................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of persons............................ Showers Cafeteria Design Other fixtures ------------_-g---••---- ---- •--••••-•- •-•.••--- ----•--••--------•. ---------------Lf-J�-------------------••--•--- WFlow............................................gallons per person per day. Total dailyflow_.__...----_._•-............................gallons. 1:4 Septic Tank—Liquid capacity.-•---__-_Cgallons Length............... Width................ Diameter---------------- Depth................ Disposal Trench—No..BOO 6........ Width.................... Total Length.................... Total leaching area----_---------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (A) Dosing t ( ) ~' Percolation Test Results • •Performed•oby._-_.__ ! w... -�t ! F-� '?.................. Date........................................ a a Test.Pit No. I.................minutes-'per inch 'Depth of tTest'`Pit.................... Depth to,ground water........................ Gi, - Test Pit No. 2................minutes per inch • Depth of Test Pit.................... Depth to ground water........................ "......----------------------....................................................................... � - Descptioti of Soil._..._ .... ._..__ ._._r ..` (. U i, ...........s------- --------------------------------------------------------------`---------------------------.....---------------------....------...-----...---...............:_-------------- w 1 V1 Nature of Repairs or Alterations-Answer when applicable_________________________________________________ ~. Agreement: y. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code--The undersigned further agrees not to place the system in operation until a Certificate of/6rpplia-ace"-as�been-issued by the board oaf health. t Signed --------- n..zwj - - `. 1 .....8..-------------------------- Date Application Approved BY ------------------ c d Date Application Disapproved for the following reasons- ----------- --- -------- ------------------------------------------------------------------------------------------------------ ............................. .......................... �.:.... Date Perm-it_No. ............. _.:` _. .��. ................ Issued ......... -- --_------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ TOWN OF BARNSTABLE -- — Cer#tft.ca e u Chum Itttx>< e� ��� THIS IS TO CERTIFY�Tlhhat Individual Sewage Disposal System'constructd ( or epai-------------------- ... n ry a as been installed in accordance tprovisionso,nIIU... of The State�nEnvironmental'-----------------................................ E 5 T ,q?'; 9� . I. ...,...; bed+in the application for Disposal Works Construction Permit No. � ode as �Nri���------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS�UED AS A� UA(RANTEE/THATyTHE--�"-a---"— SYSTEM WILL FUNCTION SATISFACTORY. DATE_.. --�.----�._...._... Inspector .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ilispnsa1 arks Tnnitrudinn rand# Permission is herebyanted.. _ n- ._....._�'_. .4X.............•--••--------•---•-----..............-•----.......................•.. . v to Construct ( ) or Repair (� an Individual Disposal system at No................. /,.4Z �_....?._..._f����`=- �,�Y�``��� Street�� .. as shown on the application for Disposal Works Construction Permit No.71�... Dated.......................................... ........................................Bo, of Health DATE.............��3.. .�.1.. ............. .`......--••- \ FORM 36508 HOBBS B WARREN,INC.,PUBLISHERS (D QJ®1VE►S' IUD . _ _ GENERAL NOTES 0 w 1. Contractor is responsible for Digsafe notification, Verification of Utilities Z 0 and protection of all underground utilities and pipes. S 34D 04 20 W \ N 1 2. The septic„tank pn ddistri ution box shall be set 1 w 3/4 —9 1 2" stone. U 111.00' 3. Backfill should be clean sand or gravel with no \ stones over 3" in size. RP'137 Camalback Rd' . a 4. This system is subject to\ ,inspection during installation a� by Carmen E. Shay —' Environmental Services. c E 5. The contractor shall install this system in accordance \ Y 0 r_ with Title V of the Massachusetts state code, the approved plan and Local Regulations. \ b �' 6. If, during installation the contractor encounters any a SHED \ > soil conditions or site conditions that are different *26 O ko —' from those shown on the soil log or in our design 4�De installation must halt & immediate notification be Oft made to Carmen E. Shay — Environmental Services. Failed 43D8 0 7. No vehicle or heavy machinery shall drive over the Q �• LEACH PIT o� septic system unless noted as H-20 septic components. E Lcmn 8. Install Tuf—Tite gas baffles or equals on all outlet tee ends. °oo E 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. w m 10. All solid piping, tees,& fittings shall be 4" diameter °' Schedule 40 NSF PVC pipes with water tight joints. EXIST. \ 3 BE HOUSE FLOOR SCHEMATIC 11. Municipal Water is Connected to ALL OF The Residence and Abutting 1000 gal. O 1 \ Properties Within 150 Feet. Septic Tank I Vent (Description Provided By Owner) 0 Pipe THE PROPERTY LINES ARE APPROXIMATE AND t COMPILED FROM THE SURVEY PLAN BY LEVY, ELDRIDGE & WAGNER ASSOC. PROJECT BENCH MAR DECK ENTITLED:AS BUILT FOUNDATION PLAN OF 137 CAMELBACK RD, M MILLS, MA TEST HOLE #1 DATED MARCH JULY 2, 1990 TOP OF FINISH FIRST FLOOR l "`;0". ELEV.= 97.00 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN ELEV. = 100.00 (Assum d) I I IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 3 BEDROOM I t 0 ' 'z� TEST (HOLE #2 THE SEPTIC SYSTEM INSTALLATION. ti y'::•. EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE EXISTING ELEV.= 97.00 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE HOUSE FROM THE EXISTING CESSPOOL/LEACH PIT TO BE DISPOSED FULL foundation GARAGE ;>. OF AS PER BOARD OF HEALTH SPECIFICATIONS. #137 o O 21' 19.5' g�I PLOT PLAN OF PROPOSED SEPTIC SYSTEM UPGRADE PREPARED FOR Lo T 3 I ASPHALT o DRIVEWAY D O U G LA S S 8c J E N N I F E R DUFF .� VD to 2-0 AT / 137 CAMELBACK ROAD ASSESSORS MAP 047 PARCEL 160 ' �e9o� � / I MARSTONS MILLS MA \ \ "'66,9 ----' \ ���Or MAS,44 PREPARED BY: � 3 � I T 3_ 96 N 34D 04' zo" W SHAY ENVIRONMENTAL SERVICES 0 20 40 50 18� P.O. Box 1576 OA MELBA C'I� �� . S 1 S-1le MASHPEE, MA 02649 SCALE: 1 "=20' TEL/FAX : 508-294-7498 (40 FOOT RIGHT OF WAY) }l SCALE: 1 "=20' DRAWN BY: CES DATE: MARCH 28, 2017 PROJECT#137 Camelback FILENAME: 137 Camelback.dwg SHEET 1 OF 2 VENT PIPE, Least 24 inches tall) *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Schedule PVC w/Charcoal Odor Filter [h;�seI min. from C0� SECTION A -A EXISTING Foundation to septic tank D-Box cover must be I within 6" of GRADE AROFI•LE' VIEW OF LEACHING SYSTEM I, 'Septic'tank covers must be '+ within AT finished grade within to GRADE w/Steel Cover `• Grade over Septic Tank - 99.00 Grade over D-Box- 97.00 INSPECTION cover m ado over SAS 97.00 3 HOLE H-10 - withhinin 6 8 In. of finished ed grade DIST. BOX /s•to r 1/8 taeAed CruOad se"W at 1/2"- 1/2• Iras ud Ppeaetone s< S 0.02 Sm0.01 15 EXIST. 1,000 GA TOP OF SAS 94.00 EXIST. PIPE FROM FOUNDATION a SEPTIC TANK 7b' s C3 C3 C3 0 C3 C3 o REM H-10 C3 0 0 0 O O C7 II an sae. � M 15' �2•sp►eaaa ava C] O CM O C3CONCRETE FULL FOUNDA y lam. A Ki p, C3 0 ai d II c SYSTEM PROFILE d ° M > > � y 2' 4 Units 6 Z4'24' 2' Not to Scale C i 5' PF OVIDED c _C7 d 4' ,' 4' % 9 Length NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE 8 in.of 3/4" 1 /2 _� /f EFfectIvv. Le th compacted stone Effective Width c SOIL ABSORPTION SYSTEM <SAS) m Bottom of Test Hote , Elev.= 85.00 LC-6 H-20 LEACHING UNITS / WIGGINS PRECAST Not to Scale PERCOLATION TEST ALL OUTLET PIPES FROM THE ;.,;. ;•,.,•;,." ;,. ..-.:;..: .;. �:�.,.,:;�: DISTRIBUTION Box SHALL BE t2. = i'—� `= : •=� SET LEVEL FOR AT LEAST 2 FT. CONCRETE COVER •f� 2-18" DIAM. ACCESS MANHOLES ' b Date of Percolation Test: MARCH 28, 2017 ,..;.. 3 - 5"OUTLET .`.. 'aM..a•;..:..c;+. 2• Test Performed By CARMEN E. SHAY, R.S., C.S.E. �' KNOCKOUTS / w Results Witnessed 6y:DAVID STANTON (BARNSTABLE BOH) _ v s INLET EE5 EXCAVATOR: CARMEN SHAY - 5.5' OUTLET "� ( 12" MET `� °11 T Percolation Rate: Less Than 2 MPI ® 42" :16: THE ACCESS COVERS FOR THE SEPTIC TANK. _ �•} DISTRIBUTION BOX AND LEACHING COMPONENT 15.5 4" - SCH. 40 Te 1.75" � ;..-;; •�-,.--•.-- .-- SET DEEPER THAN a INCHES BELOW FINISHED Test Hole Test Hole GRADE SHALL BE RAISED TO WITHIN 8" OF No. 1 No. 2 PLAN SECTION CROSS—SECTION STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PLAN VIEW INSTALL TUF-TITE GAS BAFFLES OR EQUALS 0 97.00 0 900 DEPTH SOILS ELEV. DEPTH SOILS ELEV.7.00 3 HOLE H—10 DISTRIBUTION B O X 3-24" REMOVABLE COVERS Loamy Loony / 10 YR 3/2 10 YR 3/2 3" rain. clearance 0"- 6" AP 96.50 0 6" p° 96.50 P LOT P LAN INLET 8" min.T 2" min. Inlet to outlet INLET•T' • Sandy Sandy - _-- -t 6"min. OUTLET 10"min. r I U UTCrTever - Loam Loam ca 5' _7" --- 5 14'o`-- '�5' 6"- 42" '° 93.50 6"- 42" '° �: 93.50 OF PROPOSED SEPTIC SYSTEM UPGRADE e a- a- min. Med. Mid. PREPARED FOR bONm. LlQuid depth t id S and/ S Y d/ + + 2.5 2 .:• DOUGLASS 8c N IFER DUFF "•..•, .?: •:•.c•,.. . t .,.." •F:.•.;r....." ,. �,.:' ,. .. - :.i _ 85.00 _ 85.00 74 74 JE N 4' -10"'" 42" ,44 C, 42" ,44 C, AT CROSS SECTION END—SECTION 137 CAM E LBAC K ROAD NOT TO SCALE ASSESSORS MAP 047 PARCEL 160 TYPICAL 1000 GALLON SEPTIC TANK MAR STO N S MILLS MA Number of Bedrooms: 3 Equivalent to 330 Gal. Day 330 Gal. Day per Title V Design Calculations f LeachiGarbang Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) St�Of Mgss PREPARED BY: apacity Septic Tank - 2 x330 Gal./Day = 660 us Wt�%,,ODD GAL. Septic Tank. r SHAY ENVIRONNENTAL SERVICES SOIL ABSORPTION AREA: Usingercoioll <2 min. inch Perc #1 P / Depth to Perc:42" to 60" Bottom Area: 0.74 gal/day/sq. ft. x 30&q. ft. = 227.92 gallons/day Perc Rate= 2 MPI iy gal./day/sq. q gallon/day Groundwater Not Observed Sidewall Area: 0.74ft. x 156 s ft. 115.44P.O. BOX 1 576 5�� Xd ��: �a Providing: =343.36 gallons/day No Observed ESHWT MASHPEE' MA 02649 ADJUSTED H2O Elev. = None Sa Lurltt , I TEL/FAX 508-294-7498 Use: (4) LC-6 H-20 CONCRETE CHAMBERS, HAVING A 1' EFFECTIVE DEPTH, SCALE: 1 "=20' DRAWN BY: CES DATE: MARCH 28, 2017 (3' W x 6' L) TO BE USED WITH 4' OF WASHED STONE ON THE SIDES AND 2' OF WASHED STONE ON THE ENDS AND 1 FOOT OF STONE UNDER J PROJECT#137 Camelback FILENAME: 137 Camelba k.dwg SHEET 2 OF 2 _______ __ _. �, _ i � . , .. . l ',, _ ` . '7 ,+ -11 • . - . GENERA A, . 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SAN/TARY TEE <JF THE P/ F1lSU S 4R A P TANC E '4F" f ?• r m O O.O �� Anw a, cxFi�. vv/rH ccAy FREE �� I. e c SA1VP A/VP GRAVE. h'AYiNG,4 PERG' �AT/ON . (2 ! T YPI.C44 PISTI?IBCITION BOX R,4 TE OF 2 MINClTES PER INCH OR:LESS. I.to i 1� � E �Jcot�r l t� NOT TO SCALE -,"- , C C THE15Ar_tJS F3tcBOARP O HE'A1,7j l MUST` T T _ TYPICAL ,,,�� l-IIN6 PI r NOTE`' PISTh'IBUT/ON £3OX,4AIP/J CAI,,. _ b-. NOT TO 8E 41077,41E 9 HE.N T11Z SYSTEM IS NEAR' y SC,gL,E ' OBSERV4TION" PITS i4E/Nf"f�Fs'C "L' S f'T/C TANK ,BY C`DiLJP,t,ET/ON AND PR/4rQ T4 3ACI Fl 1;%JUC. . TYPIC,4L #000G.41,.� SEPTIC TANK PERCOZAT1ON RATE = }�'kJ' l'i _i,�d A1►�1Ef?/CAN PREC,�4.ST OR EQZIA�4, 7, UNLESS OTHERWISE NOTED,AC L SYSTEsI�I ` DBSEit'Y.4T10N5 8 Y- _; t =- n ► I NOT TO SCA1 E C'CJtt-fPONENTS SHsI,G,I, BE //VSTA�..I,EO 1N ' NOTE TANKS i�'E/NFORCE"l Tf1h'OUG1/OUT . !_ B0,4RG t?F1A1,TH ACC01PP,4NCE" W/TH TITLE" Y'',aF 71 E ST.4TE 1 t/1Tt1 E/ ECTR/C lNE1 G' "P fY/r�'Ef'1 TN . - fz". 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