Loading...
HomeMy WebLinkAbout0012 CAMMETT ROAD - Health 12 Cammet Road Marstons Mills - - - \ A= 079-019 4 t_ i i a�q- of9--oo� Commonwealth of Massachusetts :. p Title 5 Official Inspection Form I klv� r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address II-- / tGhe-rd- GZlit 1 ✓7 Owner Owner's Name information is q j/S 1�J� l! v 0' cc V5 required for every page. City/Town State Zip Code Date ofl spec on Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, I use only the tab key to move your Name of Inspector cursor-do not use the return key. Company Name �b �oX( I —Q Company Address ol rim City/Town Sa C�60 � State Zip Code Telephone'NGrnber License Number B. Certification 1 certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the syst 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7 Inspecto 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. :Sinsp.doc•rev.il26MI8 TiSe 5 of`ciai tnspeccon Porn.SeCsurace Sewage Disposal system•?age t of 18 Commonwealth of Massachusetts s Title 5 Official Inspection Form I la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Xn Owner (�/VolOwner's Nameinformation is gecbo�Y'L re wired for eve page. City/Town State Zip Code Date of In C. Inspection Summary Inspection Summary: Complete 1, 2: 3, or 5 and all of 4 and 6. 1) Syste asses: 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: 2) System Conditionally Passes: Ell One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass_ Check the box for"yes", "no° or"not determined" (Y, N, ND) for the following statements. If"not determined,° please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.00c•rev.7126/2018 ?ice 5 inspeccon Form:suosurace Sewage:)ispo"System.Page 2 of 18 commonwealth of Massachusetts f Title 5 Official Inspection Form <1' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N'11M2 Property Address (/6 1 Owner Owner's Name information i e required for every / - Qd 6!�0 is page. CityfTown State Zip Code Date of i spec' n C. Inspection Summary (cons.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below). ❑ obstruction is removed ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (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.7/2 612 01 8 `ne 5 officizi;ns?ecocn Fo=:suosur ace sewage Disposal System•Page 3 of t8 I Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name X information is required for every 9 A page. CitylTown State Zip Code Date of Inspfictiov C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **This system passes if the well water analysis; performed at a DEP certified laboratory;for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems. You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or u 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.tloc-rev.7282018 `tle 5 offaai Ins.zecaor.Foy^::sutsurf2ce Sewage Disposal system•Page 4 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address, r.9--C4 14 /111 Owner Owner's Name �01.� information is Aw 4X� /V od 6 required for everyl page. Cityrown State Zip Code Date of Ins ectio 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 `-' L or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less I-� than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion"of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. f-, 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.] V,,/ //The system is a cesspool serving a facility with a design flow of 2000 gpd- 71 10,000 gpd. r The system fails. I have determined that one or more of the above failure J 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 TiBe 5,_,ffda lnspecgon=oc+:Subsurface Sewage 6'spgsW system•Page 5 of 18 t5insp.doc•rev.7262018 Commonwealth of Massachusetts -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Id- Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of spe Lion C. Inspection Summary (cont.) If you have answered"yes'to any question in Section C.5 the system is considered a significant threat, or answered "yes'to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section GA 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 XV umping information was provided by the owner, occupant, or Board of Health ere any of the system components pumped out in the previous two weeks? as the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: � Existing information. For example: a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/262018 T;Je 5 otticiai inscecton con:Su5su(faCe sewage Disposal Sysiem.?age 5 of is I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A - � Property Address Owner O wner s Name J /s ,AA information is p�� `/ required for every page. City/Town State Zip Code Date of nsp lion D. System Information .1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x##of bedrooms): Description: / `oo C7 _ j/vv7 := 4(G G 0_a4_ry_4d,4-, 14c-o� 7_�'eo c14 zv C'? s a Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes N'o Does residence have a water treatment unit? ❑ Yes 2—No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes Fe�o information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes E No C C't 6L64, Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Tide 3 cffidal:nspecaon=crm.Sucsurace Sewage Disposai System•Page 7 of 1,8 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 04 Owner Owner's Name / information.is [lam✓� µ f `S s- required for every page. CityfTown State Zip Code Date of speqdon D. System Information (cont.) 2. Commercialllndustrial Flow Conditions: Type of Estaolishment: Design flow (based on 310 CMR 15.203): Gailons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit resent?p ❑ 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 -eadings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: �— Was system pumped as part of the inspection? ❑ Yes LSO If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26201,8 1ite 5 o fiaal inspeaior.For:subsurface Sewage Disposai System•Page 8 of 18 i Commonwealth of Massachusetts Lo Title 5 Official Inspection Form H Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name // " 13 CJ���� / / information is required for every page. City/Town State Zip Code Date of spe on D. System Information (cons.) 4. Type of S m: 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/Altemative 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: Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 47�D Depth below grade: feet Material of construction: ❑ cast iron �4OPVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): '..Ue 5 cap inspxtion=o�-.sutsur!ace Sewage Disposes system•?age 9 of 18 t5insp•doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 official Inspection Form f b � Susurace Sewage Disposals Voluntary stem Form - Not for` Y Assessments /4 A C-621 Property Address / Owner Owner's Name information is )l /„ required for every page. City/Town State Zip Code Date of In pecti D. System Information (cons.) 6. Septic Tank (locate on site plan): Depth below grade: ;eet Material onstruction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy or certificate) ❑ Yes ❑ No Dimensions: x /0 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle J —5r L4, 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 — — �&05 How were dimensions determined? - ��� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): jqv-7 191 kv;�] f1d t5insp.doc•rev.7125/2018 -me 5 01floal Inspecoon Form.Suosurace Sewage Disposai System•?age 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ' _i' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 Property Address Owner Owner's Nam�411ar information is es required for every page. City/Town State Zip Code Date of In pecti n D. System Information (cost.) 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 Elmetal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7126i2018 -1-de 5 floz'.inspe=a^.Fo!rr.Scosutfiace sewage Disposai system•?age t t of t8 Commonwealth of Massachusetts Title 5 Official c a inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Property Address Q fi4 Owner Owner's Nam2�A05 ,Q Q information is S �,� od required for every � � �/ Co r page. City/Town State Zip Code Date of l spe on D. System Information (cons.) 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 Sox (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.): kteol tSinsQ.dOG•rev.7262018 i;tle S oiScal:nsornon Sewage Disposal System•?age 12 0(t8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /4 lllardo.,; A/m/57 - Ce4 "?e _11 /2C( Property Address Owner Owner's Name n information is required for every j 7 page. 6ty(Town State Zip Code Date of Insp ction D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ eaching galleries number: leaching trenches number, length: Q leaching fields number, dimensions: ❑ overflow cesspool number: innovativeiaitemative system Type/name of technology: --- -- .me ;nspet on Fc-m:Suos�2ace Sewage Disposai System•Page 13 of 18 ;Sinsp.doc•rev.',/262018 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ak AL �� � A� Property Address /10 Owner Owners Name a information is s 4 6 C y required for every hf ' Y'd page. City/Town State Zip Code Date of! specji' n 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.): N2 ✓1 �-o/ ( CA 11 L -KI,1[4 `> 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.): tSinsp.00c• ev.72612018 Tale 5 Off-cai inspea!on-O,t- SUCSu,i2C2 Sewage Disposai System•Page 14 of 18 Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Z4 G Property Address Cs /I Owner Owners Name information is Q required for every page. Cityrrown State Zip Code Date of Ins Action 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.): 't6insp.doc•rev.'1262018 Tiue 5 o taai.nspaccon=orrn.Swsu6ace sewage Disposal System.?age t5 of t8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments essments Property Address i Owner owners Name liV _ information is required for every a 4S < page. Cit /Town State Zip Code Date of In pecti 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 buildin eck one of the boxes below: ❑ and-sketch in the area below drawing attached separately i i i � I I / I i v Ii I I I I A Ili i .. i i t5insp.doc•rev.7/26/2018 Tice 5 r ficzi irspecDor.=en:SuCsurface Sewage Disposal system•Page 16 of 18 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE OCATION�Z� C 47,"/1fP,77 RD SEWAGE q ' o f ILLAGE d / _ASSESSOR'S MAP&LOT� _/y INSTALLER'S NAME&PHO1,TE NO.tV11-1 ,#W 1211 4M IMOR n4r—? /p SEPTIC TANK CAPACITY LEACHING FACILITY:(type)sCi T.p. 5 (size) 62 NO.OF BEDROOMS BUILDER OR OWNER 5R,"PQ/74/� PERMrIDATE: 3 f 2 COMPLIANCE DATE: STa3�U� Separation Distance Between thc: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist oft site or within 200 feet of bathing faci4ity) Feet Edge of Wedand and Leaching Facility(if any wetlands exist within 300 feet of leaching fs•_ihty) Feet Furnished by �e 14-1 -A' � i I-S-1 - ta3 I 6-3 4 3� I I - 5-R 1 https://www.townofbamstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?... 8/1/2019 BENCHMARK: SPIKE IN UP Q ELEV.=100.00 99 �© 'L .-6130 4 •95 EX SHED TO S RAZED 96 EX. D G O 00 TO BE ZED PROPOSED 11PU X UNIT #1 2 BEDROOMS O F. EL.,97.8� O o. 4 � c� o UNI•T . MAP 79, CLEANOUT 2.BEDROOMS LOT 18 F.F. EL.=9Z8 \'196 PROP. A 8' SEPTIC TANK 0' a : O h i D-Box / �17 / b A 2'x2 x25'L cn TRENCHES N SEE DETAIL O ® J MAP 79, LOT 19 rya #12 CAMMETT ROAD MAP 7! r LOT 18 II cn , (A c� 025 SCALE: 1"-30' Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 4—r�(/( f ✓l Owner Owner's Name A- page.information isrequired for every 4i!/s; (d7s City/Town State ZipC Date of Insp ctio D. System Information (cons.) 15. Site Exam: {_ I Check Slope ❑ Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked; date of design plan reviewed: Date ❑^ / Observed site (abutting property/observation hole within 150 feet of SAS) Checked with loael Board of Health - explain: Gi PIS 1- %2s-Y- �S ❑ Checked with local excavators; installers- (attach documentation) ❑ Accessed USGS database-explain.- You must ribe how yo established the high ground water elevation: Un OCa4&Av-� L1)17401o� N, c-4aG�eS 6Z avo 114S cs kl� /V N • f 4,r�- Before filing this Inspection Report, please see Report Completeness Checklist on next page. tsinsp.dot•rev.'2&2018 -ilie czi rspewon=0-:SuSsur'ace Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Id- eu-4 Property Address Owner Owners information is NaWay_,571�, required for every / page. City/Town State Zip Code Date of I spe ion 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 21-'Cinspection Summary: 1, 2, 3, or 5 completed as appropriate 1<1 4 ilure 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 Tice 5fiaa:fnsperuon=o-n.Suosurtace Sewage Disposal System-Page 18 of 18 t5insp.doc-;ev.7/26/2018 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of•the form. Important:When filling out forms A. General Information �II n on the computer, use only the tab . 1. Inspector: key to move your cursor-do not Brian K. Tilton use the return Name of Inspector �.y The Building Inspector of Cape Cod Company Name PO Box 307 p Company Address Eastham MA 02642 Citylrown State Zip Code; 508-255-9343 S14392 Telephone Number License Number f -+ f 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 16.340 of Title 5(310 CMR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority s } T C 9/05/2014 rispector's Signature ,e ' 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. Low cj/10 /1 � l t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owners Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) e + Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ti Comments: c; All components in place and functioning as designed. t I 14 B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): N/A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M r 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): N/A I ❑ 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): El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): N/A C) .Further Evaluation is.Regvired by the Board of Health: ❑ Conditions exist which require further evaluation by the Board!of Health in order`to determine if the system ig'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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. r ❑ 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: N/A **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A 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 El ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is.below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a`surface water supply or tributary to a surface water supply. ❑ ® Any portion of a.cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion,of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion ofa 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.] El ® ;; 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 ;•ti, 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Cityfrown 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? ❑ Z Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. 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 t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump.pump? El Yes ® No rqs. Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? F El 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: N/A t5ins•3/13#'F. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/user N/A Date Other(describe below): N/A General Information Pumping Records: Source of information: Owner/Town Hall records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: .gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 3/4/2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'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.): No evidence of leaks or clogs 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: Sludge depth: t5ins•3/13, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Accusludge, Baffle stick&tape measure Comments (on pumping.recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): light solids flaoting throughout effluent, no evidence of back up or leaks, Tees in place. Recommend pumping for regular maintenance and every 3 years.N/A r z Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/Agallons per day Alarm present:.,. ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) a 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.): Speed levelers in place, light solids carryover, no evidence of clogs or leaks lawn over top. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4@25'X2'X2' ❑ 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.): Lawn and light shrubs/plants over top, no evidence of back up or break out. No ponding or damp soil noted. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth:—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum,layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•3f13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments note condition of soil signs of hydraulic failure level of ondin condition( g y pof vegetation, 9, 9 etc.): N/A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments > 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately B GARAGE UNIT A UNIT B 2 � 1 � A7l. NOT TO SCALE A1= 18' B1= 23' A2=23' B2= 18' A3=30' B3= 26' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 B Cammett Road Property Address Nadezhda Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope T ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12'+ no water encounteredfeet 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. 3/19/2002 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: Approved design plans on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 12 B.Cammett Road Property Address Nadezhda Pokrovskaya, Owner Owner's Name information is required for every Marstons Mills MA 02648 9/05/2014 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection.Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /A o w►e I' Rj( ,cdo,% Property Address ��?? p 1,2a G e -s di-,-� 7- -Tnr.n / //74 0, do X ! Owner Owner's Name ' information is / required for every a o�o� page. City/Town' State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, jj � Lj6r7 use only the tab 1. Inspector. key to move your cursor- not l j 2A n C use the return key. Name of Inspector 'Q Company Name \ Company Address'�'° tea✓'s�`ah s /il. //S �J� ��1� City/Town State Zip Code s ok a sy 3 S� 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. 1 am a DEP approved system inspector pursuant to-Section 15340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails, ' ❑ Needs Further Evaluation b the Local Approving Authority Y PP 9 rs or's Signature Dateystem 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. t5irts•1 tllo Title 5 ofNdal speetion f rfaoe Sewage Disposal System•Page 1 or 17 i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property O Address pp -�- Owner ULlG ly , /)r"", /, Owner's Name information is required for every ���fl�v. 419 ( a page. City/Town State Zip Code Date of Inspection B. Certification (coot.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 9/1 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t&ns•1 Ino Title 5 official inspection Farm:Subvirfaos Sewage Dispose System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address uG e jd , 7 I R Owner Owner's Name information is required for every �e� 7'�r✓, _ ��6 3 a —o?S'o201.2 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven.distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Tribe 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �a Gu.-hv�e 7F /°S nn&l7`v�:s 141"111 �1i9 Property Address Owner Owner's Name information is AAn required for every LP-1 it/y,1 C �2 ? ^�- a?�o?0�v2 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal 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 ❑ d Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 91, Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ L7 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow (Sirs•11110 Title 5 official hspectim Forth:Suburface Sewage Disposal System•Page 4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments La Property Address Owner Owner's Name information is d required for every C.P-&f�/v.IQ ��/ o a �� a p 1--2- page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ d Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [r� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ [2"' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 2 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 12 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. ❑ Gall', 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. t5ins•11/10 Tide 5 Official InspecBon Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /u? CAe>,7me Property Address Owner a,< Owner's Name information is required for every n =o?5 '070 page. City/Town state dip 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 ,_,/ /fro R«fl o� �y►�✓.' Uv ❑ Pumping information was provided by the owner,-toccupant, or Board of Health ❑ [Er' Were any of the system components pumped out in the previous two weeks? 2"^ ❑ Has the system received normal flows in the previous two week period? ❑ Q� 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? 9' ❑ 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: 41211, r«alvls L7 ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: y Number of bedrooms(design): Number of bedrooms(actual): c DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Lrroe 5 orriaal Enspedim,Fomr.Surface Sewage Disposal system•Page 6 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner owners Name information is // required for every �rh ��d yr ( P /r't �? Yf o�5 ' a page. City/Town State Zip Code Date of Inspection D. System Information Description: , /500� sro>, � 7u k , lJ-h�z . �/- awx a"o xas Number of current residents: yH k Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes F'-No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes 2 No Water meter readings, if available(last 2 years usage(gpd)): Detail: # /a �q '2 0/0- Zia,yo0 ao/l - lfd ovn aaia _7 000 '13 ao/o - '7a,00V aoii - z6 00o a0i01 - 3 y o00 Sump pump? ❑ Yes B No Last date of occupancy: Date CommerciaUlndustrial 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: t5iris•11/10 Title 5 official 6nspadian Forth:Submzface Sewage Dim system•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �7 Pete-%f 4rt T Tri Owner Owner's Name information is , required for every Ce i fv�✓.Ile /-�rf 1;2 a 0/21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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: [91� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy 21- Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SyDste/m Form-Not for Voluntary Assessments h Property Address �- p Owner Owners Name information is required for every L.*� o/a page. Cityr town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes Ef"'No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron EK460 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: . feet a• y r fads 8�' Material of construction: Erconcrete ❑ 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) 201yes ❑ No Dimensions: r^�" x Sludge depth: „ t5fns•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Rd "a'001 s1.1Ns 'Iq I/s ,.9w Property Address ��--77 �7- !/uG-Py, �rru-1 /, T/4 Owner Owners Name information is required for every C��?rir� t �9 09L 3.2 7- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? f4f`v� Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �/ /- n r.r tiv�c / PG�rtn,rY►�ci / !/rho,��. -C ot� !/�'t�i, I� P i✓1 f f 0���7e DPP S So owl 8�..O k ter/ n�1 a�a� 0�;X 7' vt✓P®^Y e1ox/ 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 ou t tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official tnspecbon Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments X� � �� mot, �ls�2 G �a s a s "OP Property Address n _ TX Owner Owner's Name information is / required for every z� 14R. Q2,132 2-a �OlO2 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendation Inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, a 'dence of leakage, etc.): Tight or Holding Tank(tank must be pu ed at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float s itches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /,? Co ,;,i .>'te7� Property Address n✓,4.-. T. 7W �li l f y /3 Owner Owner's Name information is required for every Le�7ttr v, /{ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): DOXri abox G�'/I�eors J'A S00el Lo�+���0°'1, level. �Swt a�� G•vr�h f o"� So�GrS /_ur/'y�e� �/9�'► �g..►k '/l� /'1ldDvylA'1tn� /DOcMj>:�y /a--f k �o✓' N'Y*,n�t+4�•c( /Ia5 ✓',jrf— 7o — 47 /X/vw 4,r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, co dition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r 4 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -/-f Aw Property Address ,Oae-e,�t . �►r.kr % 7R Owner Owner's Name or information is 'l/� �0 6 3.Z �'a s=y���•2 required for every a-: Pr.., � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number: [� leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools(cesspool must be pumped as part of inspection)(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 t5ins•11mo Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L0dr70`14 74 /C? filar S ?`o`=S Property Address Owner Owner's Name information is required for every L.e4 y.vel, l� � L 7--o? page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs ydraulic 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 ydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 title 5 Oflidal Inspection Forth:Subst0ace Sewage Disposal System•Page 14 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments IL Property Address ,z e�r/'�h 7*-74 Owner Owner's Name information is required for every G p� c e i f ,/P V l/l W 7 a7 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately _. A t- 4 /9� a3 30 a9 yi 5,3 t5ins•11/10 Title 5 Official tnspection Form:Subsurface Sewage Disposal System•Page 15 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form-Not for Voluntary Assessments Jr� f%a o l yn e / r Property Address Q ,,Inv ��'.cth �r T/ � Owner Owner's Name information is / required for every f P-"i 7'°� �i� � ?& S'aodd page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: L� Obtained from system design plans on record 3 — L/-0a 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/hig�hf ground water elevation: {Vi'PN/t�/JP/ /1 G16t/�{ Df�f� �PS �1A61 14-"S die!Ile 0 114 foeP1- 4 a-lv- a a % ,Q_o.N. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11110 Tits 5 Official Inspection Form:SLbaufece Sewage Disposed System•Page 16 or 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1,1e l0 Oaf Property Address A ' e�, S-,l?,, T //1 Owner Owners Name information is s/b,'0 required for every Gf � �_� 00,: 3� —.2 S—aQ!°Z page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked [�Inspection Summary D(System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater [Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 o(fidal Inspection Fans:Subsxfeae Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 1 TOWN OF BARNSTABLE t nON;5�/'7 CA092,4177 ZeD SEWAGE#'PL22_0 :J GE��Q�.a'P��`'�4 ASSESSOR'S MAP&LOT41_ INSTALLER'S NAME&PHONE NO.NI,4(/.6r11►7 - SEPTIC TANK CAPACn Y /SOO. B.IL LEACHING FACUJW:(type) 6 (size) NO.OF BEDROOMS_ BUILDER OR OWNER S A T PERMrrDATE: Z 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 oti site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(tf any wetlands exist within 300 feet of leaching facility) Feet Furnished by 14_/ A' 3 36 )a http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=07901900A&seq=1 7/23/2012 COMMONWEALTH OF MASSACHUSETTS MASS.DEP APPROVED TITLE 5 SYSTEM INSPECTOR a> _J John C.Aalto c 775 Mistic Drive to Marstons Mills,MA 02648. S113565 I 4/30/2012 5/1/2015 1 e PURSUANT TO THE GENERAL LAWS AsBuilt Page 1 of 2 TOWN OF BARNSTABLE pp OCATION�I� X1,17 ,F/T- SEWAGE f4�2-—0,97 LAGS �l�4 ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO.W11-1 6 W - SEPTIC TANK CAPACITY /6 L9(9_ LEACHING FACILITY: (type) 46 Ti�.6".f.�, S (size) 62rJ� 6 NO.OF BEDROOMS_ BUILDER OR OWNER S5Y/AQr�C/ G//1/e 71,aw PERMITDATE: 3 (2 COMPLIANCE DATE:, a3fU� Separation Distance Between the: i%lasimum 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 A3 3 � 6-3 3� 1 --�- 5R http://issgl2/intranet/propdata/prebuilt.aspx?mappar=0790190OA&seq=1 8/2/2019 oFt r Town of Barnstable Regulatory Services MUMST9 ASS. g Thomas F. Geiler,Director E1639- '0 Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 19, 2002 To Whom It May Concern: This letter is in regards to the septic system design at 12 Cammett Rd., Marston Mills. On March 12, 2002 a disposal system construction permit was issued to construct a new septic system for a 2-family dwelling at this location. The permit is valid if the existing house is demolished or if it is just renovated. As long as the original design of the system does not change drastically (i.e. design flow, size of trench, etc...) and meets all of Title V requirements the existing permit is valid for three years. Thank you- 0 , . Lee McConnell, Health inspector Barnstable Health Division a t ' TOWN OF BARNSTABLE LOCATION/ /ZZ: ,2-a SEWAGE ®95 VILLAGE , �� or�i/6�`�4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /f5�0eALn PX,>110 SEPTIC TANK CAPACITY /�®� LEACHING FACILITY: (type)as (size) 62 S NO. OF BEDROOMS BUILDER OR OWNER 7' PERMITDATE: 3 2 COMPLIANCE DATE:- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet ,Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t4-/ -� / S� -.3 Fee / --r� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ��✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for &.spool 6petem Comwuction 3dermit Application for a Permit to Construct)Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 1a CoN''M4e7r Owner's Name,Address and Tel.No. 5�✓avcGC G�NJr Assessor's Map/Parcel 0 0 I'J'aUw s�. W' *Pwv-[,� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �-,jf i/ba� G�. G,rCtc✓! `�iSt�'JK� L.E,�� �,/�`li�ce�-r �ih e �f Me 63377.53: Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(V6) Other Type of Building d ir_41 . No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow o gallons per day. Calculated daily flow 44-G gallons. Plan Rate Number of sheets Revision Date Title�$su✓�Kc� EXC 1.6 1, Size of Septic Tank 1.Sa0 Sx_, Type of S.A.S. /s �4aS aLs LduY� Description of Soil 66`l-tf5 5c—�` 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 issue b t ' of Health. Signed Date Z 12—a L Application Approved by L Date a /a b Application Disapproved for the following reasons Permit No.�(����-C12< Date Issued N9.~�t v�i: ? a �y� •�� `Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC.HEALTH'DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS i application for Miopool 6potem Construction Permit - h Application for a Permit to Construct)Repair,(. )Upgrade( )Abandon( ) ElComplete System ElIndividual Components _ Location Address or Lot No. Q &..rreTr Owner's Name,Address and Tel.No. t. )0sv/1t64(,C Assessor's Map/Parcel i k Installer's Name,Address,and Tel.No. .t Designer's Name,Address and Tel.No. Type of Building: f� 4 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building 6? No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow' ¢ gallons per day. Calculated daily flow � >� ,., , y g P Y. y ��C' gallons. Plari. Date" Number of sheets Revision Date f Title A55v e4 4c C i Size of Septic Tank 45e)o y c, Type of S.A.S. rr J / Description of Soil 66`14 Nature of Repairs or Alterations(Answer when applicable) s f Date last inspected: I Agreement: ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system f in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issue• b t ' Bea of Health. Signed Date Z 1?'0'Z Application Approved by Date /:D Apolication Disapproved for the following reasons � _ t Permit No. f 6"� -C�< Date Issued c THE COMMONWEALTH OF MASSACHUSETTS f BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY. th t the On-site Sewage Disposal System Constructed)Repaired ( )Upgraded( ) Abandoned( )by �T/ I\Jn , UX!! V e at P_�_N has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�C'i� -�Cl dated Installer Designer a r c� The issuance of this pe tt shall note b/e�c strued as a guarantee that the syst in will functio�as desi'_tWe�. Date ) / .n� -5, (/ Inspector ----- ------- — -------------- -------- f No, Fee 1 I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwisposar 6pstem Construction Permit Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( ) System located at C G- i��S l and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pe t. ' Date: _ I I'�i- �� -- Approved by y t — ' : I: �1--f• x / Iil_"1—pl-zcWcxf mac_. `` _ —_—_ : I Z 4n sa'• ).o•. .i._b__._ '...S.o. i T LPG — i REF •_ B •x .._- - M'U rS� ? _ Y •', ,,al Bn,••eti' O. i) �•v'a+9�Rv i i -:RER2nocti A, u N. I r _ __, .•o•r,.._. � ..' � :bids. castB.crvrarK- - I I C . Zvo`u�aRR ��� 0- �. •.; _ OI .. .._. a _:` _ i j .o i; P.RF�.?tR7>✓1.--�� � _4. .�;,;._. �}.. i �� I ,I-' Id.o^.•..--" �a::e' :L r.ir - b Boric e— e pl z.o'.z.�'. xc. i_o c: `ti• so : tp• ve' JI zi.a' 9tr _ ---__— _---_-- _-..}. rrl.m.n.'1' p:an•an°Ityo��:°)'OCl)> : m•.. �:�' n^v v;nr�.::'..:�..::. c�P^�!. 1 - .lv 1—IL� - . u( I aecle',uxn. P�aJ I - i ; ---------------- alldi'llI -- I ------------ a (( li — m r _.._;. -•- -- -. 5J1 ILL LAW --- • � � _•. 1fKC:'dDT6Tc.'4J4EYlniL:P.Si.'TT.CItlFIS-_CJ.t?:E41-.AS�L:-�:.�.-__'.:...- .. ���' .. _ � ,J ' Uye�ST�Nww SWtt'Fs u.E4•." L . i QfllaFlElt___.._ - ;i n _ io� � _ -ait"Tti.zue-r�coarJr�- I 1 .':_�jFtZTt111TKti za'{a- `----- ------14 4---'-- g _ Ll n 9 � I '� I 'A�FWeE2 m I • ' fu• :ota^Io-rxer Iz:a^ .� --- � i`—I ¢n��t5-: � ' ... ..Z-c�-)✓l/51�11a:4---- - ��..._ g-�Yt3a•.:p1UFT>�uO.VFY_C � I o _� _ _—�_---. ._.__ _ rra�n•�na,y or pco, �p�c f�+:?.r 1— --- __ I I \l,_ 1 I —:AAxrRR7°J-"Ri l`.• _ _ _ I - 1 s,-nBMP� r F C. I a, xau I ------------- ED �wona�racl: � � d 1 i a r �t ' n rron�,.nr rLT I . ss 1•A �10 ( I ..c.r 1I •q.f b2_ `a:J ar -os ��a.r...n\s �O i — nlo'q.jlt>�:it<'�]t:l+,nro Ynn.ylnn!<>�M1oln:]rr,nl la]lu]nl rol,<F.O�R Yo tlnoYFl On r.lnF'0 YrFnim�l,•x ... -- ____ ..._.___... ----_ ��r--��-• Frni u I Fill no J1 --- ui: t. •A3A lA 7A3i un4•7t4&U ��I�no�9 Yii�..i��� o Ynn Yino, .�r s OJG VO r ooYai n ciG V:an�in�ia:n � �t a® \vvl e \w.� `•vosa —YADi3,.(SfO:�'-' __-_ mxw�.a c.� --- I .. I\,�:_._�" .S2H°IC7S212GF.-s�-.+I •w _n\a - 1 i i......_..-.L L M ue•_on.:a I :' ,. -wa aSGnOL�Oi� x I xl fllllfrr ! �. W- N v II_ u m Let __ _. 3wraonsva,wa� 3.�"VI rTi PXTS— •p of -P res 4 ! I � A�INL� 6 :saiTctTOP.'+r'S 0 - 0 9'2 Av i � �'Lre--nlmcazs- I : �.. ! � 'L�r 1 •J�P II.1 �•+:B 'O.S '0.2 d�[ o.q vumll a .,s:.n smo e, ,io v 'anl,ol v R.a DO sa.......ems I aia ¢,•�:mav,o 1 ..:� ___.._._.____._.—__ N GRAD SYSTEM DETAILS AND SCHEDULE OF ELEVATIONS LEACHING AREA ' LONGITUDINAL SECTION PVC, (.W) 4 P.V.C(S40) AN BACKFILL :1 —2X vs[ 1500 GAL SEPTIC TANK -2x -?X 314 TO 1-112 WASHED STONE 24* a ' PRECAST-REINFORCED UNSUITABLE MATERIAL TO BE REMOVEDCROSS DISTRIBUTION TO A DEPTH OF 88.6'AND REPLACED N/N. 5' TO SECTION BOX W MIN 10 LF CLEAN SAND OUNDWATER � ,6 LF I 8 LF I 25' I 2- PIPE. 4'PERFORATED P.V.C. OR APPROVED EQUAL SEPTIC TANK DETAIL S12E-1500 GAL TANK is CONFORM TO ITTLE 5 R£OIAREIEIV7S BENCHMARK: MAMiaE SPIKE IN UP 0 9 BROUGHT'OF ELEV=IDD.00 ,(� °°°°°°°°°° °o°O°°° °°° °°° °°° F#M GRADE q� ° 3 CLEAR ° 3'CLEAR ° 6'MIN. 6'MIN. e A INLET TEE ° JO'MIN. 2'MIN. 101N/N. ° TE OUTLET TEE DEPTH .g$ qO MET AND OUTLET °° $ 14'AT UOUID DEPTH OF 4' TEES TO BE 540 P1r, a 4'—OUNIUU#Ao 19'AT LIQUID DEPTH OF 5' CAST"OR PRE— o QUID DEPTH o 24'AT UOWD DEPTH OF 6' CAST CONCRETE ° WAIM77CHT CONCRETE ° 29"AT UOIAD DEPTH OF 7' 9) $ CONS1RllCRCri a 34'AT UOUID DEPTH OF 8' \ o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BOT@Y OF TANK DN LEVfl.STABLE BASE gs TANK TO BE ABLE M W714STAND N-10 LOADING CMLESS UNDER ORl1£ OR PAW MT, WERE H-20 LOADM IS REOU87EQ DISTRIBUTION BOX DETAIL Na OF OUnETS'_A_ Q TANK TO CONFORM TO TITLE 5 REQUIREMENTS o 0 0 0 0 o e o 0 0 o REMOVABLE COVE? MAP 79, au REau�As ° LOT 18 1 ° 6' a ° �96 0 1 B• waTERncHr CONCRETE coNsnrucnoN BOTTOM OF D—BOX ON LEVEL, STABLE BASE INLET TEE PROVIDED WHERE SLOPE OF INLET EXCEEDS 0.08X OR IN A P Qftl a t4 `M�y4rt4�o Ot�u s ROSS S, '� 8 DAME HM. M 5g SYKES NO.36650 )VERDIG MIS CPAL i � '.�o '�OKTLT�•O /4d �+iro11ALC►ra 3-7-oz, s i oz PROFESSIONAL LAND SURVEYOR PROFESSIONAL ENGINEER tibREVISION DA TE I DE5CRIP MAP 79, LOT 18-2 PROPOSED SEP77C SYSTEM 112 CAMMETr ROAD MARSTON'S MILLS, MA EASTBOUND LAND SURVEYING, INC 41 MEETINGHOUSE LANE P.O. Box 1188 SAGAMORE BEACH, MA 02562 (508) 833-7753 APPLICANT ASSURANCE ExcavanON 550 WILLOW ST. YARMOUTH, MA 02601 DESIGNED BY:R.84 SCALE: AS NOTED CHECKED BY.6 DATE 3-4-02 E00250 SOILS OBSERVED TESTS WERE CONDUCTED ON THIS LOT TO DETERMINE ITS SUITABILITY FOR SUBSURFACE SEWAGE DISPOSAL. DATE OF TESTING : 2-8-02 WITNESSED BY DAVE FENTON L BOARD OF HEALTH PROPOSED SEPTIC SYSTEM INVERTS. TEST PIT TOP SOIL PERCOLATION TREN( 1 !N: 9267' PIT DEPTH ELEV. TYPE RATE (MIN/INCH) D-BOX OUT. 9283' 1 144' 96.1 MEDIUM SAND t2 MIN/IN D-BOX IN: 93.0 1_ 144' SIZI MEDIUM SAND Q MIN/IN TANK OUT: 93.20 TANK IN 93.45 P Tp y2 BLDG OUT 94.37 0' 91T.1 SL 85.J 1—Z 33-1 12 AT SANDY LOAM SANDY LOAM 7.5 YR 6/8 7.5 YR 6/8 68 9..4 72' 2D-6 GRA ' MEDIUM SAND 92' 20T 10Y VEL 6 S. 10Y/R 8/6 MEDIUM SAND 1OY/R 8/6 84.1 144' a., 1Ac9�Q1 NO INDICATIONS OF SEASONAL HIGH GROUNDWATER OBSERVED t G0 t:61:70 ELEVATIONS SHOWN BASED UPON AN ASSUMED ELEVATION tl�4 a DESIGN CRITERIA: EX SHED SOIL CLASS 1, LIAR LOADING FACTOR-0.74, y TO B RAZED PERCOLATION RATE>2 MIN/INCH, 4 BEDROOMS O 110 GAL/DAY b EX D G 00. FS7IMATED DAILY FLOW: a` �^� TO BE ZED PROPOSED 4 BEDROOMS x 110 GAL/DAY/BDRM - 440 GAL/DAY 1JPLEX REQUIRED LEACHING AREA: 44OGPD/0.74 - 595.0 SF t%rH7(11 2 BEDROOMS PROPOSED SOIL ABSORBTION SYSTEM: F.'F 4 TRENCHES, 25'LONG gg fF SIDES 41f(2x2x25)+(4x2x2) 464 SF 4 0, BOTTOM 4x(2x25�=200 SF T O $ UNIT.I ��� 2 BEDRi LEACHING AREA: 664 SF IS > 595 SF F.F.'EL PROP. s SEPTIC TANK 0' GENERAL NOTES. a y 1)ALL CONSTRUCTION TO CONFORM TO THE REOUIREMOM OF THE MASSACIHISE TS r D- TITLE 5 REGULATIONS AND THOSE OF THE LOCAL BOARD OF HEALTH. n ) 2) THE ENGINEER MLL NOT BE RESPONSIBLE-FOR THE PERFORMANCE OF THE l SYSTEL UNLESS CONSTRUCTED AND INSPECTED W ACCORDANCE NTH THIS PLAN. INSPECTIONS TO BE DOME AFTER EXCAVATION FOR AND CONSTRUC17OV OF THE / SYSTEM,BUT PRIOR TO BACNFlLLING ANY ALTERAnpV MUST BE APPROVED IN NRITING BY THE ENGNEER 3)ALL VEGETATION, TOPSM SUSSM IMPERVIOUS AND DELETERIOUS MATERIALS 2•x•x25'L\ IF ANY, MUST BE EXCAVATED AND REMOVED TO A POWT 5 FEET BEYOND l THE PERIMETER OF THE PROPOSED LEACHWG MIEld AND SHAD.BE REPLACED SEE DETAIL WTH CLEAN SAND AND CRAVn W ACCORDANCE WITH TITLE a N -Z•J 4)SEPTIC TANK AND DISTRIBUTION BOX ARE TO BE INSTALLED OR A LEVEL, O STABLE BASE THAT WU NOT SETTLE 5)SEPTIC TANKS SHOULD BE INSPECTED ONCE EVERY YEAR AND CLEANED AS REQUIRED. 0 6)NO WHI=OR HEAVY EOWPbM ARE PERMITTED OAR ANY PART OF THE MAP 79, LOT 19 7) CONSTRUCTION.UN O UTILITIES AT W AREA ROXiIATE 0NLY PRIOR TO #12 CAMME7T ROAD 4944 8)EX/STING CESSPOOLS TO BE PUMPED AND FILLED WIN CLEAN SAND 9)BOARD OF HEALTH OR IT'S REPISENTAIIVE MUST INSPECT AND APPROVE TIC INSTALLATION PRIOR TO SAWRLLNG U CA to 5025 LEGEND S - TEST alr D DISTRIBUTION BOX —100—- EXISTING CONTOUR O PROPOSED CONTOUR 0 SEPTIC TANK 100.00- DUSTINO SPOT ELEVATION ZONE RF ►41NWW SETBACK* xtOOOO- PROPOSED SPOT.EEVATION O EXISTING CESSPOOL FRONT 30' TO BE FILLED SIDE AND REAR 15' SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so that we can return the card to you. C. Si nature ■ Attach this card to the back of the mailpiece, X ❑Agent or on the front if space permits. Addressee 1. Article Addressed to: D. Is deliv ad different from item 1? ❑Yes If YEI enter delivery address below: ❑ No We ►'YIGt C����.�on 563 O-Lo SQ �I/v C I rYl 3.'Service Type Certified-Mail ❑Express Mail P1 Registered ❑Return Receipt for Merchandise v (� ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(Copy from service label) O q13 PS Form 3811,July 1999: Domestic Return Receipt 102595-00-M-0952 UNITED STATES POSTAL SERVICE First-Class Mail Postage�&Fees Paid USPS Permit No. G-10 � • Sender: Please print your name, address, and ZIP+4 in this box • I � Board of Health Town of BamddA* P.O.Box 534 j Hyannta Massedmefls 02601 I I ,l &a I t!!'!!!?l�l9P�lF!!�?!tfll�I3�lli+��lllfdi?!�!!/llPf9J3il�lfli7� Z 203 498 913 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent tow de � t Street&Number Po State,&ZIP la 1 Postage $ 3l� Certified Fee 1 U Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom&Date Delivered Q Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ -t V) Postmark or Date 0 tL 0. Stick postage stamps to article to cover First-Class postage,certified mail fee,and i charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service y I� window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the a� return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Forth 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the Cr addressee,endorse RESTRICTED DELIVERY on the front of the article. GGo . CV) 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. LL I 6. Save this receipt and present it if you make an inquiry. 102595-97-8-0145 a ! � `i f FTHE Town of Barnstable o� Department of Health, Safety, and Environmental Services MAMSTABM Public Health Division AlFON1P�A P.O. Box 534, Hyannis MA 02601 Office: 508-8624644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health February 2, 2001 Wade and Mary Gendron Map and Parcel 503 Rte 6A 079-019 E. Sandwich, MA 02537 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE II,MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 12 Cammett Rd., Marstons Mills, was inspected on January 29, 2001 by Edward Barry, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II, Minimum Standards of Fitness for Human Habitation were observed: 1) 410.190 Floor grates missing for heat vents. 2) 410.253 No globe on light fixture in bathroom. 3) 410.481 No sign posted showing name, address and telephone number.of owner. 4) 410.500 Outside walls, Asbestos shingles broken and missing, gaps between windows and window sills, ceiling tiles water stained, holes in walls, south bedroom boarded up,tiles missing from floor, windows broken. 5) 410.352 Bare wires on the kitchen ceiling. 6) 410.602 Trash in yard. dolimpi/wp/q/Is You are directed to correct violations 1, 2, 6 within twenty-four(24) hours of receipt of this notice. You are directed to correct the remaining above listed violations within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However,these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health dolimpi/wp/q/Is • V TTTTT'`�7`�T'�T�T TTT�T�TTT�T�T�TT�TTTTT TT��T�TTT� Jay Ji�rr�r.�~ .yam IIA r� hNISA CTION This Subsurface Sewage Disposal System Inspection Has Been Performed In Accordance With The State Environmental Code " TITLE V " 301 CMR 15.300 thru 15.303 March 1995 By : outh hore urvey Consultants, Inc. Registered Land Surveyors & Civil Engineers 167 R Summer Street • Kingston, MA 02364 (617) 934-7553 (617) 582-2185 FAX (617) 582-2239. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of Property:/2 Q.51I,/y/�/ZZS/ Owner's Name: Date of Inspection: PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. �f�s1 g/n/A19� None of t!psastem 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. —zThe facility or dwelling was inspected for signs of sewage back-up. —zThe site was inspected for signs of breakout. —ZAll system components, excluding the SAS, have been located on the site. P The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —zThe size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential: �2,c�q/yif/,�j�� number of bedrooms number of current residents garbage grinder, yes or no /J�&9 laundry connected to system, yes or no AW seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: IN9-74;� /O Last date of occupancy GENERAL INFORMATION Pumping records and source of information: System pumped as part of inspection, yes or no If yes,volume pumped 4�V vs' 1��,�,d!/r�T�,Q�/ Reason for pumping: Type of System Septic tank/distribution box/soil absorption system Single cesspool 1,4W. Overflow cesspool Privy Shared system, yes or no (If yes, attach previous inspection records, if any) Other(explain) Approximate age of all components. Date installed, if known. Source of information: t AW Sewage odors detected when arriving at the site, yes or no f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete metal FRP other(explain) Dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc.) DISTRIBUTION BOX: /yam (locate on site plan) depth of liquid level above outlet invert Comments: (Note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, recommendations for repairs, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued PUMP CHAMBER: y (locate on site plan) pumps in working order, yes or no Comments: (Note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc.) SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number //3dlf�kLt/f�TFse Comments: (Note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, © recommendations for maintenance or repairs,etc.) _ _ —% OF �'CLY��S�Cr�s :/Y. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued CESSPOOLS (locate on site plan): �2 number and configuration - depth- top of liquid to inlet invert depth of solids layer depth of scum layer O�� dimensions of cesspool materials of construction indication of groundwater inflow(cesspool must be pumped as part of inspection) Comments: (Note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, reco mendations for maintenance or repairs,etc.) _ i� P VV—./y`�¢ —(loeste on site plan d* mcngieng- -depili-of sefids- Comments: (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations or repairs, etc.) DEPTH OF GROUNDWATER depth to groundwater f�O�YI ���P� T��ic� � 'fyy ?iS�ol�/� Method of determination or approximation: w� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: 64-7'!5) /Yo70:G ViZ, �iy �sJ�<Y�•lia ��fiy.�7 T�iCE'T6[J���iyiLo loyc���'i t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. (If "not determined", explain why not). 14 Backup of sewage into facility? /Y Discharge or ponding of effluent to the surface of the ground or surface waters? aF/YO l>-153allr, A/V Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume <1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped /YV Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? / Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? /1-within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS)? /y within 50 feet of a private water supply well? Mess 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, dttach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector:,O�.,�-/, . L�S� Company Name: South Shore Survey Consultants, Inc. Company Address: 167R Summer Street, Kingston, MA 02364 Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: /have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment Y P as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature:/'/' 94� Date: 40/009 - Original to system owner Copies to: Buyer(if applicable) Approving Authority LOCUS ADDRESS: /2 raj W,4y 7l X/- ,, Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Water Pollution Control Technical Assistance and Training Sections William F.Weld Governor Trudy Cots Seustery,EOEA Thomas B. Powers Ad ing CommWsioner 03/09/95 ATTN: Mark D. Casey South Shore Survey Consultants, Inc. 167 R Summer St. Kingston, MA 02364- Dear Mark D. Casey, I am pleased to inform you that you have attended training, met the experience qualifications, and have passed the Title 5 System Inspector exam, pursuant to 310 CMR 15.340. The passing grade for the exam was 39/52 or 75%s. Your grade was 90%. This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15.340. You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address: Kimball Simpson D.E.P. Training Center 50 Route 20 Millbury, MA 01527 Thank you very much for your time and consideration in this matter. Sincerely, Kimball T. Simpson, DEP Training Center Director [371 Route 20 a Millbury, MA 01527 • FAX 508-755.9253 a Telephone 508-756-7281 �I outh hone uruey Consultants, Inc. Registered Land Surveyors & Civil Engineers June 9, 1995 Health Department Barnstable Town Hall 367 Main Street Hyannis, MA 02601 Re: SEPTIC INSPECTION: - #12 Cammett Road, Marstons Mills, MA Former Owner: David E. Wieland - Assessors Ref: Map 79, Lot 19 Dear Board Members: South Shore Survey Consultants, Inc. recently completed a Subsurface e��age, Disposal System Inspection in your Town and we enclose a copy of our Inspe tion Repc,Lr,b in accordance with the State Environmental Code Title V, 301 CMR, 15.30 thru 15.303. _. 661 z As per the requirements of TITLE V, Section 15.340, the individuals isted b have been approved as Certified Department of Environmental Protection S 1 �? Inspectors: dt B Henry T. Nover, P.E. Mark D. Casey, C.S.I. William P. Sylvia, P.L.S., C.S.I. Charles Fortier, C.S.I. Please acknowledge receipt of this report by signing a copy of this letter and returning same to this office. Your kind attention to this request is appreciated. Sincerely, CAW l� , Mark D. Casey, C.S.I. MDC/df Enc. Acknowledgement of Receipt of Report: Date: 167 R Summer Street • Kingston, MA 02364 • (617) 582-2185 J SOILS OBSERVED FIN,GRADE SYSTEM DETAILS AND SCHEDULE OF ELEVA 77ONS TESTS WERE CONDUCTED ON THIS LOT TO DETERMINE ITS SUITABILITY FOR 3 SUBSURFACE SEWAGE DISPOSAL. GATE OF TESTING : '� o LEACHING AREA TNESSED BY DAVE FENTON m 4" PVC, (S40) 4'P.V.C(S40) LONGITUDINAL SECTION WI ALTH PROPOSED SEPTIC LEAN eACKF^LI SYSTEM INVERTS: TEST PIT TOP SOIL PERCOLATION TRENCH IN: 92.6T —2X _2 4 r O PIT DEPTH ELEV. TYPE RATE (MIN/INCH) 1500 GAL SEPTIC TANK -29. 3/4 TO 1-1/2 WASHED STONE 24' w 0-BOX OUT 92.83 PRECAST-REINFORCED UNSUITABLE MATERIAL TO BE REMOVED if 1144" 96.1 MEDIUM SAND <2 MIN/►N D-BOX IN: 93 0 DISTRIBUTION TO A DEPTH OF 88.6' AND REPLACED CROSS IF2MIN. 5' TO SECTION 144" 97.1 MEDIUM SAND <2 MIN/1N TANK OUT: 93.20 10' MIN 10 LF BOx w CLEAN SAND GROUNDWATER TANK IN: 93.45 d 46 LF ELF, I _ 25' ; 2'� - 1 TP J2 BLDG OUT 94.37 PIPE: 4" PERFORATED P.V.C. 0" 01 0" OR APPROVED EQUAL 1�2 95_1 1 : A SL 95.1 SANDY5 618 Z5 YR 61s i SEPTIC TANK DETAIL 68" 90.4 72" SIZE 15W GAL. 9_Q._6 COARSEAN TANK 7n CONFORM TO TITLE 5 REQUIREMENTS 20Z GRAVEL BENCHMARK: MANHOLE MEDIUM SAND 92" 10Y R 816 88.6 SPIKE IN UP O BROUGHT TO 10 YIR 816 MEDIUM SAND ELEV.=100.00 99 w1THIN t2' OF 10Y R 8 6 0° o°o°o°o° °o°o°o°o°o°o°o°o°o°o o°o°o°o 00 FINISH GRADE / ° 3 CLEAR 3"CLEAR ° 144" 84.1 144" / / 84.1 1Qcg Q• ' �` 0 6'MIN. ° 6 A4/N. `(/ ` 0 101MIN. 27MIN. 10"MIN. o OUTLET TEE NO INDICATIONS OF SEASONAL HIGH (�� ,{�,� INLET TEE GROUNDWATER OBSERVED `_ `_ L-61:.7Q �Q 0 0 ounEr TEE DEPTH GO ¢ ,sg �O INLET AND OUTLET °o $ 14"AT LIQUID DEPTH OF 4' ELEVATIONS SHOWN BASED UPON ` TEES TO BE S40 PVC, 0 4'-0"MINIMU 0 19'AT LIQUID DEPTH OF 5' CAST IRON OR PRE- o LIQUID DEPTH ° 24' AT LIQUID DEPTH OF 6' AN ASSUMED ELEVATION �� a ONSTRUCTION 2 1,001 0 29' AT LIQUID DEPTH OF 7' -(p.1 9, CAST CONCRETE WA CGHT CONCRETE a 34" AT LIQUID DEPTH OF 8' G °0000°oo°oo°oo°0000000000°o DESIGN CRITERIA: BOTTOM OF TANK ON LEVEL. STABLE BASE. EX. SHED g6 TANK TO BE ABLE TO IWTHSTAND TO B RAZED. H-10 LOADING UNLESS UNDER DRIVE SOIL CLASS 1, LIAR LOADING FACTOR=0.74, 3 PERCOLATION RATE >2 MIN/INCH, 4 BEDROOMS ® OR PAVEMENT, WHERE H-20 LOADING 110 GAL/DAY ^ IS REQUIRED. EX: .D G 0 00 FSTIMATED DAILY FLOW: a ��� TO BE ZED PROPOSED 4 BEDROOMS x 110 GAL/DAY/BDRM = 440 GAL/DAY �/ UPLEX DISTRIBUTION BOX DETAIL REQUIRED LEACHING AREA: 44OGPD/0.74 = 595.0 SF UNLT #1 Na OF OUTLETS_6 2 BEDROOMS v _ p TANK TO CONFORM TO TITLE 5 REQUIREMENTS .PROPOSED SOIL ABSORBTION SYSTEM: _ F.FS EL.-.97.8 4 TRENCHES, 25 LONG _ _.. _ ____.._ co _ 664 SF o 0 0 0 0 0 0 0 0 0 0 0 o REMOVABLE COVER SIDES 4x((2x2x25)+(4x2x2)]==464 F 4 � 00 !' BOTTOM 4x(2x25)-200 SF a' MAP 79, OUTLET PIPES as TOTAL: o UNIT # LOT 18 ° i REQUIRED ° CLEANOUT 2 BEDROOMS 0 1'2" " 0 LEACHING AREA: 664 SF IS > 595 SF F.F. EL.= �.8 0 6 0 L ° 96 � 0 _ °o 0 0 0 0 0 0 0 0 0 0 0 ,9 SE TIC. B' WATERTIGHT CONCRETE' CONSTRUCTION TANK BOTTOM OF D-BOX ON LEVEL, STABLE BASE 0 GENERAL NOTES: d o WHEREINLET TEE PROVIDED SLOPE OF INLET EXCEEDS 0.08XORN A P SYSTEM. SN Of 114 1) ALL CONSTRUCTION TO CONFORM TO THE REQUIREMENTS OF THE MASSACHUSETTS r D- OX �µ1N Oi 2M TITLE 5 REGULATIONS AND THOSE OF THE LOCAL BOARD OF HEALTH. DANIEL M 2) THE ENGINEER WILL NOT BE RESPONSIBLE FOR THE PERFORMANCE OF THE / ► > + ROBB B. SYSTEM UNLESS CONSTRUCTED AND INSPECTED IN ACCORDANCE WITH THIS PLAN, gg' SMITH INSPECTIONS TO BE DONE AFTER EXCAVATION FOR AND CONSTRUCTION OF THE l /OVERDIG SYKES M NO.36650 SYSTEM, BUT PRIOR TO BACKFILUNG ANY ALTERATION MUST BE APPROVED IN I I +#35418 CIVIL WRITING BY THE ENGINEER. (n / 3) ALL VEGETATION, TOPSO(L, SUBSOIL. IMPERVIOUS AND DELETERIOUS MATERIALS, 2 x2'x25' IA at IF ANY, MUST BE EXCAVATED AND REMOVED TO A POINT 5 FEET BEYOND .-{ TRENCHES tINInE SS10kAt r THE PERIMETER OF THE PROPOSED LEACHING SYSTEM AND SHALL BE REPLACED v' SEE DETAIL � I WTH CLEAN SAND AND GRAVEL IN ACCORDANCE WITH 117LE 5. N J 4) SEPTIC TANK AND DISTRIBUTION BOX ARE TO BE INSTALLED ON A LEVEL, STABLE BASE THAT U NOT SETTLE 0 �W --7--OZ << d Z 5) SEPTIC REQUIRED TANKS SHOULD BE INSPECTED ONCE EVERY YEAR AND CLEANED AS 4 cp PROFESSIONAL LAND SURVEYOR PROFESSIONAL ENGINEER 6) NO VEHICLES OR HEAVY EQUIPMENT ARE PERMITTED OVER ANY PART OF THE SYSTEM. MAP 79, LOT 19 REVISION DATE S RI ON 7) EXISTING UNDERGROUND UTILITIES SHOWN ARE APPROXIMATE ONLY. PRIOR 'TO J12 CAMMETT ROAD CONSTRUCTION, CALL 'DIG-SAFE' AT 1-800-322-4844 MAP 79, 8) EXISTING CESSPOOLS TO BE PUMPED AND FILLED WITH CLEAN SAND LOT 18-2 9) BOARD OF HEALTH OR IT'S REPRESENTATIVE MUST INSPECT AND APPROVE THE INSTALLATION PRIOR TO BACKnLUNG. 11 PROPOSED SEPTIC SYSTEM #12 CAMMETT ROAD MARSTON'S MILLS, MA cWo 50.25 -� y EASTBOUND LAND SURVEYING, INC. 41 MEETINGHOUSE LANE LEGEND SCALE: 1"=30' P.O. BOX 1188 TP SAGAMORE BEACH, MA 02562 - TEST PIT o DISTRIBUTION BOX (508) 833-7753 — - EXISTING.CONTOUR o ��- PROPOSED CONTOUR o SEPTIC TANK APPLICANT: ASSURANCE EXCAVATION - n ZONE RF 550 WILLOW ST. 100.00 EXISTING SPOT ELEVA ON .00 - PROPOSED SPOT ELEVATION O MINIMUM SETBACKS: YARMOUTH, MA 02601 xl 00 EXISTING CESSPOOL FRONT 30' TO BE FILLED SIDE AND REAR 15' DESIGNED BY R.B.S. SCALE: AS NOTED CHECKED BY: DATE: 3-4-02 E00250 II i