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0021 CAPTAIN BAKER ROAD - Health
21 Captain Baker Road Marstons Mills � —- --- — -- - - - - - --- - - - A= 126-038 TOWN OF BARNSTABLE LOC XTION &V,2 r- IZd SEWAGE # aooS AX VILLAGE f kqf S ONS Mi(IS ASSESSOR'S MAP & LOT ��6 INSTALLER'S NAME&PHONE NO. 1UR 06r,5 Sa SK SEPTIC TANK CAPACITY 1060 44-( (o LEACHING FACILITY: (type) 4Wk";P Q G2(�irs (size) aS.� 13' NO.OF BEDROOMS nn BUILDER OR OWNER � rJ tj-e, PERMITDATE: Ira �[e~i' 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 13' F3 � 35� s 3 Y - No. 26 Fee THE COMMMMEALTH OF MASSACHUSETTS ' Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BAaNSTABLEs MASSACHUSETTS Application for ;Dtopoml *potent Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) .❑Complete System f7 Individual Components Location Address or Lot No. / Owner's Name,Address and Tel.No. 21 Ca t. Baker Road ,�/B///1 , Cynara (Watson) Connell Aisgss6o�Capt. `21 Capt. Baker Road 428-1498 Marsteas Mills MA In er's Name,Address,and Tel.No. De gner' Name,Address and Tgl.No. Cow �ucrt'o �'wc Car EngineeringLLC �o 'eox `rJa�S��.�s 1 56 Crowell Rd. Suite B Type of Building: Dwelling No.of Bedrooms 2 Lot Size 2 3,7 5 0 sq.ft. Garbage Grinder( ) Other Type of Building re s i dent i a 1 No. of Persons 4 Showers( ) Cafeteria( ) Other Fixtures Design Flow 349 gallons per day. Calculated daily flow 220 gallons. Plan Date 0 5—2 4—0 5 Number of sheets 1 Revision Date Title Sewage Disposal System Plan Size of Septic Tank EXISTING 1 000 gal Type of S.A.S. 12 .83 x 25 ' Galley , Description of Soil See Plan & Report Nature of Repairs or Alterations(Answer when applicable) Real Estate Transfer — Leaching Failed 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 t e Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee ' ed b S f ea Sign Date Application Approved by Date Application Disapproved for the following reas ns1- Permit No. Date Issued �a `' ism a2. i No. Entered`in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes, f PUBLIC HEALTHr'DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ticatiott for i o5af 15tem Con tructiw Permit � Application for a Permit to Construct( )Repair(K )Upgrade( )Abandon( ) ❑Complete System )0 Individual Components Location Address or Lot No. Owner's Name,"dddress and Tel.No. 21 Capt. Baker Road vi�l Cynara (Watson) TOnnell Assesso 'sMap/Parcel 21 Capt. Baker Road 428-1499 !+ i t-+/Y J 11i5 Installer's Name,Address,and Tel.No. De gner' Name,Adllress and Tel.No. Clams Engs.neeringLLC ra�Bah -S" y!��yo.�s w�% s 156 Crowell Rd. Suite B io�c/ Chgtham, mA niA33 Type of Building: Dwelling No.of Bedrooms 2 Lot Size 231750 sq.ft. Garbage Grinder( ) Other 'Type of Buildingr e s i de.nt i a l No. of Persons 4 —Showers( ) Cafeteria( ) ~� Other Fixtures - Design.Flow 349 gallons per day. Calculated daily flow 220 gallons. Plan Date 0 5-2 4-0 5 Number of sheets 1 Revision Date s -Title Sewicie Disposal System Plan Size of Septic Tank EXISTING 1 000 aal Type of S.A.S. 12 .83 x 25 ' Galley ,. Description of Soil_See _Phan ! Retort � b Nature of Repairs or Alterations(Answer when applicable) Real Estate Transfer - Leaching Failed k Date last inspected: Agreement: TheAndersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system { m accor dance 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 bee ' sued by is o �fbf -e • h. Sign Date Application Approved by , _ �!1 ��� Date Application Disapproved for the following reasdns v F r vg= / / 1 / Permit No. I-V In Date Issued k -� — ——— -- —————— ---------------- ——————————— - . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERT ,, that the On-site Se wa a Disposal System Constructed ( ) Repaired( x)Upgraded( ) - Abandoned( )by*` K-,9 H,u , o3 0 at a (!P�- �p has been constructed in accordance ,with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer�d "4 Cfj ,a t�tj / ,i c Designer j (-C The iscuance of this pe t sh 11 not be construed as a guazantee that rhe syste w 11 notion as designed Date� � •3T� Inspect© Ar . No. ---=--—————--—————————---------Fee- 9� v v e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migonf *pgtem Construction Permit Permission is hereby granted to Construct( )Repair Upgrade( )Ab ndon System located at -j I 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 ust be completed within three years of the date of this.perm it./) Date: �/ � v a Approved by r li FROM FAX NO. Jurl, 10 2005 04:3 'M 1�Jr•?.;�.�E��� • �'�`.•���F'�" ;Sf:,-�?r�T�±:�l_F_: �:�i4kJ r;F� H[.:�L C't; ;�w.;a'"' 1-..;:?;'�_.__ ...-....�.. Town of Harmoable TOWN OF BARNSTABLE 26n5 JUN 14 PM Public Healtya Division DIVISION Mcet 508-862,4644 F gt�5.7 t3 f►3t?d Este: Cfl-►3—0 bulpart E l k)( E Ad 6I N LqW cart Addrom . ,l .... i -S lei on J a ' .�'. h C ��l was i�5t3oel n poxrt w i.as 0- septic eyaLLL&in &aJ bms'd om a desigtt draw drawA I,y d. a C IGrk ]4k inee[,- 1`�C dated Z4-as _V I Oa'df�that tk septic syl rA gao;�d r1baye wus in&c.id jujjj;tutiWj c,r, ' the d i; wkdoj,to*•anc;luae Vc nor a3 '"o�ed rh3ngea Staeb, Ra laUlal r noatic�n ddsttfbutran ATA401 Sep*tom, of ihe �.. Y that the septic �yatrazu to .ere=ul 4E�m%ru j jnat�lLd u th m jor ohmiges 0i& gr"W thin�1 O'"latara r-ocsdoz of the-sm w.any�' rt tl rolocati=Of my orimpon ot'th�ffi gtit c s sfem, lout in wwrlt=e wit, !ph" �&bant &Load R ons. PLW ravidon or ICtTd by desigm to BollQ��=. f" �tN OF hI DAV1D A �%, •fit ,�a..r.-� �' CLARK +�nssslle e l ►x CIVIL No.41725 e Is gtT 9 v61�'°� Ebl �pu}F.{5"'AISYt, .. t - l i 4 .. .• • Massachusetts Department of Environmental Protection 21 Captain Baker Road, Barnstable Bureau of Resource Protection.—Wastewater Permitting Program Site Address or Map/Lot Number Form 11 - Soil.Suitability Assessment for Oh-Site Sewage Disposal 1A. Facility Information 1. Facility Information Cynara Connell Owner Name 21 Captain Baker Road Map/Lot Map 126 Parcel 43 Street Address Barnstable MA City State Zip Code B. Site Information 1. (Check one) New Construction ❑ Upgrade ® Repair ❑ 2. Published Soil Survey available? Yes ® No ❑ If yes: 1993 _1:25,000 EnA Year Published Publication Scale Soil Map Unit Enfield Poor Filter Soil Name Soil limitations 3. Surficial Geological Report available? Yes ❑ No ® If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes ® No ❑ Within the 100 year flood boundary? Yes ❑ No Within the 500 year flood boundary? Yes ❑ No ® Within a Velocity Zone? Yes ❑ No 5. Wetland Area: National Wetland Inventory Map .N/A Map Unit Name Wetlands Conservancy Program Map N/A Map Unit Name 6. Current Water Resource Conditions (USGS) April, 2005 Range: Above Normal ® Normal ❑ Below Normal ❑ Month/Year 7. Other references reviewed: DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 1 of 7 LlMassachusetts Department of Environmental Protection 21 Captain Baker Road, Barnstable Bureau of Resource Protection —Wastewater Permitting Program Site address or Map/Lot number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole A: 5-20-05 11:00 am Warm&Clear Date Time Weather 1. Deep Observation Hole Logs Deep Hole Number 1 Ground Elevation at Surface of Hole 71.0 Location (Identify on Plan ) Off driveway 2. Land Use: Residential none <5% (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones. Slope(%) Lawn & Red Oak outwash end of driveway Vegetation Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body N/A Drainage Way N/A Possible Wet Area N/A feet feet feet Property Line 20 Drinking Water Well N/A Other feet feet 4. Parent Material: Outwash Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: <168 60.6 assumed based on bottom of inches elevation test hole 1 = observed groundwater DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 2 of 7 LIMassachusetts Department of Environmental Protection 21 Captain Baker Road, Barnstable Bureau of Resource Protection —Wastewater Permitting Program Site Address or.Map/Lot Number Form 11 - Soil Suitability. Assessment for On-Site Sewage Disposal Deep Observation Hole A: Deep Hole Number: 1 Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure Soil Depth Horizon/ Color-Moist (mottles) Texture % by Volume Consistence Other Layer (Munsell) (USDA) (Moist) (In') Depth Color Percent Gravel Cobbles &Stones 0"-6" A 10 YR 3/2 None Loamy none none Friable Sand T-20" B 10 YR 4/6 None Loamy none none Friable Sand 20"- C1 2.5 Y 5/6 None Loamy none none Friable 120" Sand 120% C2 Medium Loose 168" Sand - Additional Notes DER Form 11 Soil Suitability Assessment for On-Site Sewage Disposal - Page 3 of 7 } Massachusetts Department of Environmental Protection 21 Captain Baker Road Barnstable Bureau of Resource Protection Wastewater Permitting Program Site Address or Map/Lot Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole B: 5-20-05 11:00 am Warm&Clear Date Time Weather 1. Deep Observation Hole Logs Deep Hole Number 2 Ground Elevation at Surface of Hole 70.7 Location (Identify on Plan ) Off driveway none <5% 2. Land Use: Residential Surface Stones Slope (e.g.woodland, agricultural field,vacant lot,etc.) Lawn& Red Oak. . outwash end of driveway Position on landscape(attach sheet) Vegetation Landform 3. Distances from: Open Water Body N/A Drainage Way N/A Possible Wet Area f Net feet feet Property Line 20 Drinking Water Well N/A Other feet feet 4. Parent Material: Outwash Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Ob served: Yes ❑ No H ° If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: >120 24.0 from USGS map inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 4 of 7 19 } Massachusetts Department of Environmental Protection . 21 Captain Baker Road Barnstable Ll�� Bureau of Resource Protection ' Wastewater Permitting Program sire Ada�ess o�Map/Lot Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Deep Observation Hole B: Deep Hole Number: 2 Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure Soil Depth Horizon/ Color-Moist (mottles) Texture % by Volume Consistence . Other De p Layer (Munsell) (USDA) (Moist) (In.) Depth Color Percent Gravel Cobbles &Stones 0"-T A 10 YR 3/2 None Loamy none none Friable Sand 6"-20" ' B 10 YR 4/6 None Loamy none none Friable Sand' 20"- C1 2.5 Y 5/6 None Loamy none none Friable 120" Sand. 120"- C2 Medium Loose Sand Additional Notes • DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 5 of 7 Massachusetts Department of Environmental Protection 21 Captain Baker Road Barnstable l Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method used: ® Depth observed standing water in observation hole A. 168 assumed B. inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ❑ Depth to soil redoximorphic features (mottles) A. B. inches inches ❑ Groundwater adjustment(USGS methodology) A. B. inches inches 2. Index Well Number SDW-253 Reading Date 04--2005 Index Well Level 49.4 Adjustment Factor 3.6 Adjusted Groundwater Level 60.6' NGVD E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes ® No❑ b. If yes, at what depth was it observed? Upper boundary: 20 Lower,boundary: 168 inches inches F. Certification certify that I have as ed h Aoil evaluator examination* approved by the Department of Environmental Protection and that the above d training, expertise and experience described in 310 CMR 15.017. analysis was perf m b consistent with the require 05-20-05 Signature of Soi " aluator Date David A. Clark, PE July 1995 Typed or Printed Name of Soil Evaluator "Date of Soil Evaluator Exam Donald Desma rais R.S. Barnstable Health Department Name of Board of Health Witness Board of Health Note: This form,must be submitted to the approving authority with Percolation-Test Form 12 DEP Form.11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 6 of 7 s • Massachusetts Department of Environmental Protection 21 Captain Baker Road Barnstable LLI: Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Use this sheet for field diagrams: • DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 7 of 7 r l FORM 12-PERCOLATION TEST Location Address.or Lot No. 21 Captain Bakers Road COMMONWEATLH OF MASSACHUSETTS Barnstable, Massachusetts Percolation Test Date: Date: 05-20-05 Time: Time: 11:00 AM Observation Hole# 1 Depth of Perc 64" Start of Pre-Soak 11:26:00 End of Pre-Soak 11:41:00 Time at 12" Time at 9" 11:48:00 Time at 6" 11:54:00 Time (9"-6") 00:06:00 Rate Min./Inch <3 Min/inch *Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Suitability Assessment: Site Passed X Site Failed Additional Testing Needed: Performed By: David A Clark P.E. Clark Engineering Witnessed By: Donald Desmarais R.S. Barnstable Board of Health Comments: 08/31/2011 10:41 15089455450 CLARK ENGINEERING PAGE 01 T&N OF BARNSTABLE LOCA-nON 071 SEWA + 36 VELLAGE tNglsist-A3 M,(IS ASSESSOR'S &L©T a I INSTALLER'S NAME&PHONE NO. a 2t Se5' SEM TANK CAPACITY fr h) LeACMNG FACIL ; (type) kt..t . 6 jj j j:s _(size)�r.... No.Of BEDROOM S 0 pp / R UR.ER OR WME i1S (` A.• !V'l'i 1 FEXWTDATF--ijl-V-6,'^5 COMPLLANCE DATE: Sepa kdon Ditume Between the. Maximum Adjuftd OroundwatexTabie to the Bottom of•Leachizlg Facility Private Water Supply Well and Ltaching F=Xty (If aay wclls exist an site of within ito fcct of 1404hing facility) feet E*of'6vallaad and L.E eWng Fsoility(It may wetlands exist wititiu Sao fut of leaching f;icivty) ' c Pw rushed by .._..... .....ram... w. 1 Ax, 1: A n 9' '3 'Search for IVlapParcel 126038PEN ` Town a BarnsYabie A FF?arcel Num 126038 *, Rntaf F operty /N �r Business Name% orb of Contribution( of ��` ��' � Gontam�nant�Rel(Y!N 000 !/xi/% c 0000000 d �P, one ti ,Ue St ra"�a Tank-Rer k w riar�y�f rrr x tCard�Onte� � Const RM ruction t T , FilelPermrt 2005236 fi Issuance Date F , i 05/26/2005 ... r Complett9ri Date r 05/31/2005( r r 41, Sae of�SeiUc r ti Type/SofSASa 12 83 x 25 galley y Tank '' ' x1000 , r is� � � Commenters �, R _ - lj failed septic 5/9/05 R&H 2 BEDROOM***NEED BOTH*** ` mappar 126038rO�yver WETMORE CYNARA A �D ol W 21 CAPTAIN BAKER ROAD r ,��a�`�� � � I�ino�attuelAiternative T'echnolog ySe fic S stem"s '�� Sin to or., stared i mW ShM x 6 SearChf /Pra I126038 r' ' Toft wn fBernIe A�i � wl ParceilN mu l 126038 � ' � � p�x{y(y � e taloRrO a !N OF 'Business ama / pf�� ZgneofCantnbu io (1! i ll NUm_ber / �g Conta iant Rdiff ] p e 000 00000 C Fuel Storage Tan Rerm�t ' my GartlO fff p %i �/ / I?erc Test 1Vel er�mit Coastcti n i� `" / � v w, FilelP/rmNo / /ice � �sce ate 05/26/2005 S. 1� J CompleU n Date / /a lv y , jj �Szeof Septic Type/Size of SASS 12 83 x 25 galley x1000 ° Ma �� Spro— failed septic NW05 R&H 2 BEDROOM***NEED BOTH*** mappar 126038 Owner WETMORE CYNARA A rgpioc 4 21 CAPTAIN BAKER ROAD / 4l d ¢ � ON / innovatry lAlternatiueecfinology eptiaSy tams Smgie or �" !A Tye ;� I/A�Ser�i�Ge Typed �l gypte f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owner's Name required information forls Marstons Mills MA 02648 May 18, 2011 every 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: A. General Information When filling out forms to the I n computer,use 1. Inspector: U only the tab key to move your Darren M. Meyer cursor-do not Name of Inspector use the return key. n/a Company Name VQ PO Box 981 Company Address East Sandwich MA 02537 City/Town State Zip Code 781-424-6748 S13920 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit 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. U ,.glot5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo I Syse 1 f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every 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 l5ins•09/08 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 °M 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information required forts Marstons Mills MA 02648 May 18, 2011 every page. City(Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply wells". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than ''Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , s 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '�M ,•''V 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2009: 213 gpd Detail: 2010: 243 gpd Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. City/Town 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: ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts ro Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installation date unknown, but within the last 6 years. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(Locate on site plan): Depth below grade: 12"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 signs of leakage. t Septic Tank(locate on site plan): Depth below grade: 14 inches 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: typical 1,000G tank Sludge depth: 12 inches t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. Cityfrown 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 22 inches Scum thickness 4 inches Distance from top of scum to top of outlet tee or baffle 5 inches Distance from bottom of scum to bottom of outlet tee or baffle 10 inches How were dimensions determined? tapes and rods Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level equal to outlet pipe, structural integrity is sound, no sign of leakage, no sign of hydraulic failure, PVC tees with baffle is in place, tank in need of pumping. 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 t5ins•09/08 Title 5 Official Inspection 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 �^M 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is ,Marstons Mills MA 02648 May 18 2011 required for � every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylehe ❑ 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 switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 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 wM 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every 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 n/a Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is level, riser in place to within 4"of grade, minor signs of solids carry-over, no sign of leakage, no sign of hydraulic failure or overflow. 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 l� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): 2-50OG chambers with 4ft of stone on all sides, chambers 36" below grade w/no riser. Vegetation normal, soils normal, chambers are holding 3 inches of water, with a stain Line at 6 inches. 18 inches of available leaching. Units appear to be H10 loading. 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•09/08 The 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owner's Name information required forts Marstons Mills MA 02648 May 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. CityfFown 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 DECK ` I I I � pov-H 2 1 -r F,s � A-2 .35 r6 9 -2 '. 33 '� l5ins•09/08 Title 5 Official Inspection 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 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 144"+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Bottom of system approx 6 ft. below grade, hand augered to 14 feet, did not hit any water. Thus system is not within adjusted groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 21 Captain Baker Road, Extension Property Address Federal National Mortgage Association Owner Owners Name information is required for Marstons Mills MA 02648 May 18, 2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION ' O" C �AktC iXT SEWAGE # VILLAGE M• /V►a0 ASSESSOR'S MAP & LOT—IL�Os INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY d�U r nn �+® LEACHING FACILITY: (type) V'T �6 �A� sv �) NO. OF BEDROOMS C�— BUILDER OR OWNER Cofrj, l I PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leacyng facility) Feet Furnished by-Z"/1s17Gc Dn 'S ro/cl' 0 Sly Q� III i a3 q u a W) l c� 3 as 3� TOWN OF R k,RNSTABLE 1'I LOCATION' aeZh 'SEWAGE # � VILLAGE ASSESSOR'S MAP LOT / -- 037 INSTALLER'S NAME & PHONE NO. � ��/ Go••�� �3� SEPTIC TANK CAPACITY /GOB LEACHING FACILITY:(type) A'�7/7_ size) /D NO. OF BEDROOMS 13 -PRIVATE WELL OR P LIC WATER BUILDER O OWN DATE PERMIT ISSUED: -7/. '93 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 6 a7 p 37 n a L) s I � , COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 'Fu�VL-.{�•i�. p TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 21 Captain Baker Extension pl pE�T��� Marston Mills. MA 02648 F IE.D INSPECTION S Owner's Name: John Cornell Owner's Address: Date of Inspection: Mav 4, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:! Passes Conditionally Passes = k CD Need Further Evaluation by the Local Approving AU t ortty -q ✓ Fail cr3 ru Inspector's Signature: Date: Mav 9 2005M � cn N. D The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Healtkor CO DEP)within 30 days of completing this inspection. If the system is a shared system or has a design f ow of 10#000 rm gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional Lffice of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments **"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Captain Baker Extension Marstons Mills. MA Owner: John Cornell Date of Inspection: May 4. 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exftltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Captain Baker Extension Marstons Mills, MA Owner: John Cornell Date of Inspection: May 4, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Captain Baker Extension Marstons Mills. MA Owner: John Cornell Date of Inspection: Ma 4. 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Captain Baker Extension Marstons Mills. MA Owner: John Cornell Date of Inspection: May 4, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Captain Baker Extension Marston Mills. MA Owner: John Cornell Date of Inspection: May 4. 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped I %years ago-,per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: AQe unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Captain Baker Extension Marston Mills. MA Owner: John Cornell Date of Inspection: Mav 4, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(orr condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 zal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not aj2pear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: , Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Captain Baker Extension Marston Mills. MA Owner: John Cornell Date of Inspection: May 4, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 i Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Captain Baker Extension Marstons Mills. MA Owner: John Cornell Date of Inspection: May 4. 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): The pit was full. Liquid was yL to the inlet pipe. The pit showed signs offailure. The bottom to grade was 8'6" The cover was 12"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Captain Baker Extension Marston Mills. MA Owner: John Cornell Date of Inspection: May 4. 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 0 S, � Q` A a3 q u a an I G 3 as 36� 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 Captain Baker Extension Marston Mills. MA Owner: John Cornell Date of Inspection: May 4, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic.,naps and water contours map, the maps were showing approximately 25'+1-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 RtO E0 Al,A .,I$ORTOLOTTI CONSTRUCTION, INC. 8 �999 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648j �BARNS?, �l 508-771-9399 5118-428-8926 FAX: 5118-428-9399 � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ti PART A CERTIFICATION Property Address: — Date of Inspection: Inspector's Name: — er's CRTIFI ATION STAT M NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: ✓ Passes Conditionally Passes Needs Further Eva atio a oval Aproving Authority Fails Inspector's Signature: !� pale: 3 cJ The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION S 1MMARY• A)SYST M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; - One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): 1 - SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM _ PART A `CERTIFICATION(continued) - Broken pipe(s)replaced -E Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced , Obstruction.is removed 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 the public health,safety and the environment: 1)SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF,HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT'THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system his a septic tank and soil absorption system and is'within ithin 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The stem has a tic tank and soil absorption system and is within 50 Feet of a private system septic water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm: �•._ _ _ _ .. .. . _ _ D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool•. Static liquid level in the distribution box above outlet t invert'due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below nvrf ora'vailable volume is less than 1/2 day flow. . Required pumping more than`4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) d Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. -=-Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private } . water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant. threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply ;* 'The system is within 200;Feet of a tributary to a-surface drinking water.supply The system is located in a nitrogen sensitive area Interim.Wellhead Protection Area (IWPA)or a mapped Zone Hof a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00'. 'Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: , -t/ Pumping information was requested of the owner,occupant' and Board of Health. I/None of the system components have been pumped for atleast 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. __je�'`I'he facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding.the Soil Absorption System,have been located on site. ,,,'The septic tank manholes were uncovered,opened,and the':interior of the septic tank was in- s ed for condition of baffles or tees,material of construction,dimensions,depth of liquid, epth of sludge,depth of scum. , The size and location of the Soil Absorption System on the°site has been determined based on existing information or approximated by non-intrusive methods. -3- 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) facility owner and occupants, if different from owner)were provided with information on The a ty ( p , the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM"INFORMATION' " / . FLOW CONDITIONS RESH)VINTIAL: v 1 Design Flow:-]3.; ons Number of Bedrooms: o? Number of Current Residents: '7 Garbage Grinder:_ Laundry Connected To System: Seasonal Use: �g7 Water Meter Readings,if ilable: Last Date of Occupancy: - COMM .RCLAI rINDUSTRIAUVO Type of Establishment: Design Flow: allons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: - -- Non-Sanitary Waste Discharged To The Title V Systenv Water Meter Readings,If Available: ` Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection: If yes,volume pumped: >;allons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(.If es,attach previous inspection records, if any) Other(explain): �f aVAl S'. s AP ROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site:/V ' -4- sr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C ,GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: �` Material of Construction: ✓concrete metal FRP 0ther (explain) _ Dimisions: ?.5'X lv ',r ' Sludge Depth: Scum Thickness: Z Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: /10 ' Comments:.(recommendation for pumping,condition of inlet and outlet tees or baffles; depth of liquid � level in relation to utlet invert, structural integrity, vidence of I akage. etc.)�Q�� 2 /pp '' aza GREASE TRAP: AA Depth Below Grade: Material of Construction: concrete metal FIIP Other (explain) `" — — — — Dimensions: Scum'Thickness: Distance from top of scum to top 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, etc;) TIGHT OR HOLDING TANK:- Depth Below Grade: Material of Construction:_._concrete—metal—FRP_Uther(explain) Dimensions: Capacity; gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches. etc.) DISTRIBUTION BOX: 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,etc.) PUMP CHAMBER:., M - Pump is in'working order. Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) d -5- __ �,-ty�1'+(yk�Saft n a., . F � ., ` i. i - '1-';. } � � `�j���/ '. fli . ` • . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIiL 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, number:-.,� ,. Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure vel of nding,condition of vegetation, etc.) GYM _,/ !1 CESSPOOLS:__ZJb Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. r. On 0 DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Appf oximation: 1 je:�'5'01'e-ele' Po /�iiGa/ u/Yi�! .S. ,S -7- No.... + Fas. ................ THE COMMONWEALTH OF MASSACHUSETTS Ate® BOARD OF HEALTH TOWN OF BARNSTABLE ��tll�tt� f�rr-�i►��11��1 �nrk,� C��ttl��r�r�inn rrnti� Application is hereby made for a Permit to Construct ( ) or Repair P14 an Individual Sewage Disposal System at: _Location-Address or i � ---------------3-9 '...----------------------- /L�............................ Address/77Owner o................................................................................................. ...---•••--................... / Installer Address " Q Type of Building Size Lot.•�5,!___rpa'_--. j .Sq. feet Dwelling— No. of Bedrooms................�--___-___-__.____Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- W Design Flow................- ........_____gallons per person per day. Total daily flow_._................�3d...........gallons. 94 Septic Tank—Liquid capacitye ..gallons Length................ Width---------------- Diameter_--.--_________- Depth................ W Disposal Trench--No. .................... Width_...__......._...... Total Length__........._........ Total leaching area....................sq. ft. x � 3 Seepage Pit No.......... ..... Diameter...16/........ Depth below inlet...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- -----•---•----•----•-••-•---•----•-••-••---•--••............---•- Date........................................ .aa Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit__._____•-_.____--_- Depth to ground water........................ GY -------------------------------•-.......................-•-•..........................-••-•--•-.............•---•-•••••----•-••............--••--------...... ODescription of Soil...................................................................................... -----------------------------------------------------------....--•••------.----•• V .... .-•----------------- ••----------------- .........----------------------------- ------------------- -----•----------------- ----------------------------- •---------------- •----------- -------- .----------- --W ------------------...- -----------------------------------------------------------------•-------------------------------------------------------------- .._. . U Nature oepairs or Alterations—Answer when applicable._.--,r4-...A0......... ...... ..-------•-G� - ........-- •- --•----`........ vl...----••------..._7�.......���sT✓�� �! ���_.-T `�'`� j�'rl....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has' e n iss � a byhe rd of health. 7/Signed ...............>..........-...-.-.....- ...._ � / ApplicationApproved By ..... . .... ....."- ............................................................................. ...... �. -.5......7_3 Dare Application Disapproved for the following reasons: .. ........... .............. ........................ .......... ........ . ............:...................... ................................................................................................................................................................................................................ ........................................ Date Permit No. -...:_l.-3........ )...7.-2..................... Issued ........... .... .--..--.. --g........ .-.-..... \ Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE '� 7 1pf irattolt �or Diripoti 1l HlDrbi Towitrurtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair (P< an Individual Sewage Disposal System at: 71 16, 6 -------------------------------------------- ........---•-- .............................................................. // Location-Address J7 or Lot No. 2iZ4 Owner Address , 1 �� 04 94 Installer Address f.. U Type of Building Size Lot_Z_5/.Ei��..Sq. feet ►, Dwelling— No. of Bedrooms_________________� ------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____�________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QOther fixtures --------- -------•---•--•-------•------_.---•-----------•-•.................... ............................................................ W Design Flow................... .S...............gallons per person per day. Total daily flow................... ...........gallons. WSeptic Tank—Liquid capacity/Ak.galIons Length................ Width__...-_-____.___ Diameter---.------------ Depth......................... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No------- ----- Diameter Diameter-__/X!.._...._. Depth below inlet......�:>.......... Total leaching area..................sq. ft. =Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date-----------.......------------------.... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil.......................................... W x •----•--------------------------------••-------...... ........................................................................................................ ........................................ U Nature of Repairs or Alterations—Answer when applicable____- .,4.1.,0............. ..... �J7 �"/--.. :�" .S d ..� .. =� .....__. ........................................................................................--- .. ---• -------------- ....... _ •---- ....... Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has fbeen ss ed by the board of health. Signed ..... U--------------- ...%_: :..�� / :...... /�111k7,l / ......../...Daze... ........... Application Approved BY 4 ........ ..-E -.�.�- .� ........... ."a.-...�:55....... .3 ....... ... . ......................... Date Application Disapproved for the following reasons: .... . .......................... .... ... .............................................................. ............... ..... ............ . .... . . .............................. . .......................... --- . ..................................... ........................................ Date Permit No. ........7 ------- ....17-9....................... Issued ............... ..-.... --. ........ -------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cnez#tftca e of C11ompliance THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b / �� -7c T/..................C:_G... mil�i�G l .....---..." Instauer at ....... . ......... . . has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......�` ..-...3-9;>-,--------- dated ----------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... .... . ..-----.... ...._. ......................................... Inspector -------------------- _._.. .. .. ....._..... -- ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / c� �cl� TOWN OF BARNSTABLE No...........' FEE........................ Disposal Workii Tomitrudivit Wrmit Permission is hereby granted................ 21C_J�7..._....._C_Gives /LCJc:-7[; 1------••---------------- to Construct ( ) or Repair ( Q. an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit Dated....... - .............................. .............................................................. Board of Health DATE.......... 3-.................................... " FORM 36508 HOBBS&WARREN.INC..PUBLISHERS Town of Barnstable P# 2/66 Department of Regulatory Services ' Public Health Division Date le .5 S a+uuvsn+ar$, � i �� 200 Main Street,Hyannis MA 02601 OtEb NII�� Date Scheduled Ttme �/ Fee Pd. Soil Suitability Assessmentfor Sewage Disposal Performed By: Witnessed By:�rlwo� LOCATION& GENERAL INFORMATION Location Address ` o� /1��✓x�r�--��Owner's Name W .3 Address Assessor's Map/Parcel: f� �, / Engineer's Name NEW CONSTRUCTION REPAIR `� Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) Depth to Bedrock f . j Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: ___ in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjuttrteat ft• 1 Index Well# Reading Date: Index Well level., AdL factor- Adj.Groundwater Level!q PERCOLATION TEST Bete, Thu Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ lime(9"-6") End Pre-soak ' Rate Minllnch X Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the r Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munselt) Mottling (Structure,Stones,Boulders. Consistency.% ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselt) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselt) Mottling (Structure,Stones,Boulders. Consistency. Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, h� I ' Flood Insurance Rate May: Above 500 year flood boundary No_ Yes Within 500 year boundary No= Yes Within 100 year flood boundary No— Yes �. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? - Certification `, �'�-s_ I certify that on (date)I have passed the soil evaluator examination approved by the Department of En trpn rotection and that the above analysis was performed by me consistent with the required trains g,e e s and experience described in 310 CNM 15.017. Signature Date Q:4SEPT1GIPERCFORM.DOC DEEP OBSER VA TION HOLE LOG LEGEND I ---�''� Existing Contour _ �•\ � ' Marstons Mills. T.H.11 T.H.12 Proposed Contour � '� Date of Test 05-20-05 Date of Test 05-20-05 i h a Moss. X 37.5 Existing Spot Grade 43 1 Proposed Spot Grade �� � � ' Race Lone Existing Grade Existing Grade ' �'�_ w Water Service �(" ,rf ` / Depth 0 71.0 Depth 0 70.7 ohu- Overhead Utility Line(s) . e \- A A u Underground Utility Line(s) /' sf�/c �\�2.7 ;.• �yo LOCUS 9 Gas Line / ` ems' .; ':t? ¢� Loamy Loamy �, q� 7N Test Hole and or Baring Location .;• �. Sand Sand / g �, O , ,x� Cap t. D lOYR 3/2 10YR 3/2 Q Percolation Test Location `\ > Studley Friable Friable Concrete Bound CB �� \ a� ■ ( ) r 1 �.:; _ Road S.T. Septic Tank 6 6" 70.5 " ► :: O 70.2 D.B. Distribution Box I ' CB Fnd. .f.."' -----•-----•---- SAS Soi! Absorption System ' B B RA Reserved for Future SAS. Loam Loam , . LOCUS PLAN Y }' � Utility Pole , _ 10YRn4/6 l0YRn4/6 ® Catch Basin / �' \ / `,` - Friable Friable Fire Hydrant .\ / 1 Tree or Hedge Line j ACT A 20" 69.3 20" 69.0 [15.000] Reference to 3f0 CMR Title 5 \ Assessors' Map 126, Parcel 38 \ J ------------- Loamy C 1 ;•'•'` i ; �'�`SOp ��� OWNER OF RECORD: Sand Loamy - i / \ � D Deed Book 4731, Page 43 / Sand _ _... ._..... , `\ 2Friable s 2.5Y 5/6 =-•.............................. ::_......= - ; T0*_ � .� Plan Book 374, Page 34 Friable ;7 *p� / � ----- `\ Lot 2 120" 61.0 120" 60.7 ----�` �► Z/ _�� ---- ------------------- C2 C.2qj Medium Medium �` ti �\ LOT 2 4% Sand Sand ,' _ - `.� / ` Loose Loose \ \ ---- , ' 750 SF. L NO TES CLASS I ctAss I 5 GENERA o - / ; `o+ \`\ \ �� A.) Neither driveway nor parking areas are allowed over septic 168" 57.0 168" 56.7 ` `�� system unless H-20 components are used and system is vented. B.) The designer will not be responsible for the system as de- \ 72 i signed unless constructed as shown. Any changes must be 71.5 X 71.3 71.4 `�\ approved in writing by the designer Representative of Approving Authority ; Donald Desmarais, Barnstable Board of Health \ '� Shed i `.� C.) Contractor shall be responsible for verifying the location of Soil Evaluator. David A. Clark, P.E. - Clark Engineering �� \ i '�, `. all underground and overhead utilities prior to the commencement 71.4 Percolation Rate: \�\\\ X 1 N.. of work. \'\ 717 /1 - min. per inch in , 12 - < 3 min. per inch in loamy sand;Substrotum C 1 Water Encountered. \ 1.7 X 71.5 I "� Appropriate Index Well. SDW-253 / o oar- 71.8 Existing 1000 gal Water Level Range Zone: B CONSTRUCTION NOTES \ \ \ Est `Ye//i i tic Tank to Remain , � // �,q � SeP • Water Level for index Well. 49.4 ' ` \ -- 71.8 T �3 �% o i / 1.) A!l construction shall conform to the State Environmental for Month - Year. 04-05 / _\ 7 -- 71 ��,�` '8 ; Code, Title 5 and the requirements of the local Board of Health Adjustment. 3.6 Observed Ground Water Elev.: 5ZO assumed \\ .0 i 2.) Topsoil, subsoil, peat, or other unsuitable or impervious Adjusted Ground Water Elev.: 60.6 / + \ \x 70.1 .71.7 I i 0qn / material [15.255 (1)] shall be removed rive (5) feet laterally \ \ 71.5 I * ' in all directions beyond the outer perimeter of the soil absorp- \ o / X 1'6 q 71.4 i ��er tion system to the depth of, the naturally occurring pervious LOCOt%On of the Exrs tin g , material(s) and replaced with fill material meeting the spec- Soil-Absorption System + \ ' r ificatiogs of 310 CMR 15.255(3), [15.255(5)]. . , ; per the As-Built Card on / 3.) Septic tank(s), grease trop(s), dosing chambers) and dist- 70.8 O x � O'71.1j _ file i the Barnstable ' ributon box(es) all be /e a which a 9 x 71.3 f been tnechanr compacted If component is Bork :,, r..�� �, '==::::. \ �� �- Heaftht Department Po �lpouient base rm i"N '': ::,,� \ �'� �_ ' ` f proper compaction is required to ensure stability and to prevent Pump & Remove Components '�� settling; native ground with a 6 inch stone base is otherwise �i \ CB Fnd. r , adequate [15.221(2)]. _70.0 \ ` + n TH-1 / ) aggregate / / 6 / / odeI ..X 71.z 4. Base a ate shot/ consist of 3 4" to 1-1 2" double washed stone free of iron, Vines aqd dust and shall be installed 70 from below the crown of the distribution line to the bottom of 69 9 �F`rS •._._ \ �'/ 3 70.9 , ' absorption system [ " O] " aggregate,► covered with a 2" layer of 1/8 4to 11/2 Base washed stone 0 f er , / \ ' ' �� / free of Iron, fines and dust [15.247 (2)]. �iQ e�o� / BENCH MARK.• \ �FNj = QQ \ I + SFC / Top of Concrete Monument (CB) \ y ' = Q \ 1 TH-2 ; 5.) From the date of installation of the soil absorption system E/ev.=69.40 \ ?sO' 70.2 70.5 CA U r/ON, / until receipt of a Certificate of Compliance, the perimeter of the 70.3 70.5 \ soil absorption system shall be staked and flagged to prevent Overhead Utilities + ; the use of such area for all activities which might damage the 0019 ' // \ 70.5 O I + �.; / system [15.246(2)]. ' 70. .. 1\ 1 L7/77 je _ 6.) The Board of Health shall require inspection of all construction Of D. n by an agent of the Board of Health and the designer and shall „�p q + require such persons to certify in writing that all work has been N CAL COLA TONS / � I \ 'op�o red + _ completed in accordance with the terms of the permit and SYSTEM DESIGN / C' , approved plans. 48 hours advance notice is requested 1.) Basis of Design Number of Bedrooms. 2 70.4 \ Other. / Tots 2.) Design Daily Flow Sewage now. 220 GPD � 3.) Septic Tank Capacity6g,g ' / , , s S\A0 Required. 440 Gal. / / `. ?'� �yG C Provided: 1000* Gal. s / / / \ :� / � Civrt 4.) Soil Absorption System Capacity 220 GPD ..• � / / ' � �•\ � o G q C1Af7K � � inR e4 / / No.4 Provided. 349** GPD 5.) A garbage disposal is MT permitted with this design JO�y "' o s f T * Existing 1000 gal Septic Tank to Remain ~ N ed`3 4 R�1 ** [25 L.F. x (2 + 12.83 + 2) x 0.74 gal/S.F.] + [2 ends x (2 x 12.83 x 0.74 gal/ SF.)] PROFILE OF SYSTEM SECTION A-A CYNARA A. CONNELL Not To Scale Not To Scale (2 8%) 21 Captain Bakers Road, Mars tons Mills, MA Top of Foundation 73.0 Finish Grade 71.5 _ Finish Grade 71.8 Fin 71.7 2% Slope minimum 71.0 8 min. Finish Grade 71.7P EXlS77NG Raise covers of the D-Box with pre-cast concrete water tight risers over inlet and Raise manhole cover to within 6 inches Raise manhole cover to within 6 inches CLARK ENGINEERING LL C outlet tees to within 6" of finish grade. of finish grade using precast concrete riser, of finish grade using precast concrete riser, " concrete blocks, or brick masonry. concrete bJocks, or brick masonry. , 70.7 (19J 3.0' 2.3 15ti Crowell Road Suite B, Chatham, MA. 02633 Max. Elev. Elev. = 68.7 s8.7 Tel.: (508) 945-5454, Fax.: (508) 945-5458 69.6 2% minimum slope- (6%) t 2" layer f 1/8'-1/2" 6" min. 6 min. 1% minimum slope 1% minimum stops _ _ _ _ _ _ _ _ washed sane _ _ _ _ o 0 0 0 o p o _ - _ - = SEWAGE DISPOSAL SYSTEM PLAN Flow Line - . . _ _ _ - 4" schedule 40 PVC pipe " " Outlet , es from D-box shall - - - - _ - _ - 3/4 -1 1�2 = - _ - _ I-� 10 min. 4 schedule 4Q PVC pipe 6 mn. remain�evel for at least 2 feet - El EJ washed stone _ _ _ - _ _ 0 0 0 0 0 0 0 0 14" Effective - - - Effective Effective Rev. # Description of Revision Date EXIS77NG EXIS77NG EXISTING before pitching to soil absorption _[61,:ev. _ , Dep E/ev. _ - - - - - - 0 0 De th ' a a a o ochedule 40 , 2 - _ _ - . . - Depth 2' 67.87 P 2 678TElev. = Elev. = PVC Tee " Add Elev. system [15.232(3)(c)]. _ 87 65.87 _ - _ - _ _ _ _ _ 48 min. Tuf-rite Elev. = Elev. = Q Q EJ Q - - _ - 0 0 0 0 0 0 0 0 70.57 69.6 (GB-1) 69.35 68.15 67.98 - - - • - - - - - - • ' - ' ' - ' ' Bottom of Leaching Facility 4' 4' T I 4' 8.5, -' 8.5, 4' Distribution Box 5.3' 1 adjusted High Groundwater 60.6 Effective Length 25' DB-9 Effective Width 12.83' Pipe Run Leaching Galley Date: 05-24-2005 Drawing No.: (10' min.) EX/STING 0479010A 1000 gal/on Septic Tank 20' s' to 11' (H-1 D) Scale: 1" = 20' Sheet No.: (H-10) 1 of 1