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Home My WebLink About0024 CAPTAIN BAKER ROAD - Health -Road � �i rr7 ,L c. S i s 1 r >aCo - off Commonwealth of Massachusetts rP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �9w 1 CS 24 Captain Baker Road I Q Property Address ;_4. William Koppen Owner Owner's Name <•. information is required for every Marston Mills i/ MA 02648 4-27-18 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information / l [� 1lpufllffrgpi use only he tab � t .... ur 1. Inspector: 0 4 9 . key to move yo o1'r �y cursor-do not ,lames D.Sears = JAM ES � use the returnr key. Name of Inspector s v: ,e Capewide Enterprises *' o Company Name 153 Commercial Street '�,F S i N spE��,a``°� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-2-18 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer; if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rray.6115 Title 5 official Inspection 2orm:SuDsurfaee Sewage Disposal System-Page 1 of 17 l, a6ed xed dH W 2 81.0Z 20 AeW Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � . 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary. Check A,B,C,D or E I 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: The system is a 1000 Gal. Tank D Box-Pit and Four chambers. 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.doc•rev.6116 Title 5 Orfidal Inspection Form:Subsuftce Sewage Disposal System-Page 2 or 17 Z a6ed xed dH Ot,:2 8602 20 X2W Commonwealth of Massachusetts ivTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owners Name information is required for every Marston Mills MA 02648 4-27-16 page. cityrrown State Zip Code Date of Inspection B. Certification (cons) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired, B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more than 4 times alyear due to broken or obstructed pipe(s). The ` system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 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 16.303(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 l5v,s doe•rev.6/16 T tle 5 Official Inspection form:Subsurface Sewage Disposal System-Page 3 of 17 £ a6ed xed dH Ob:I.Z 8 XZ W AeW i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston.Mills MA 02648 4-27-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 is less than 6" below invert or available volume is less than %2 day flow 4£,A(' j v( I5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Pepe 4 of 17 abed xed dH 0t,4Z 860Z ZO AeW i Commonwealth of Massachusetts Title 5 Official Inspection Form '. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Road J Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 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 Now 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. t5in540c•rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 g a15ed xed dH 0t:2 860Z 20 AeW Commonwealth of Massachusetts Title 5 official Inspection Form VP Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �- 24 Captain Baker Road Property Address William Koppen Owner Owners Name information is required for every Marston Mills MA 02648 4-27-18 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes or`no'as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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 l6ins.doc,rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 9 a5ed xeJ dH 6f,:2 81.0Z M 4eW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owner's Narne information is required For every Marston Mills MA 02648 4-27-18 page. cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank- D Box-Pit-and four chamber's. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2016-33,000Gals g ( y g {gpd)): 2017-26,00oGal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy; Present 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/sci t., 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: t5ina.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L @tied xeJ did Ov:2 860E ZO AeW Commonwealth of Massachusetts �rrTitle 5 Official Inspection Form i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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): l5ins.doc•rev.8/16 Title 5 official Inspection Form:Suosurtace Sewage Disposal System•Page 8 of 17 9 a5ed xed did I t,:2 9 602 ZO AeW f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 Permit #96-33 Leaching Chamber's 14-2018 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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.): Pipeing is PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene Cl other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3" t5ins.doc-rev.611E Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 9 of 17 6 a5ed xe� dH Zb 6Z 960Z ZO AeW f i Commonwealth of Massachusetts Title 5 Official Inspection Form `i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is Marston Mills MA 02648 4-27-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and cover at 2'. Inlet tee, outlet Baffle. No sign of leakage or over loading. 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.00c-rev.6115 Tale 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 0l, abed xe� dH Zb:2 860Z ZO XeW Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F, vW 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont,) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level, Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 151ns.doc•rev.W16 Title 5 official Inspection Form:Subsulace Sewage Disposal Splem•page 11 of 17 I,I, a6ed xe:1 -dH Zb:2 81.0Z ZO XeW Commonwealth of Massachusetts u».i Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-22" below grade w/two line's out. Box is New 4-2018 w/cover at 6" Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Now Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I5ins.doc-rev.6116 Title 5 Official Inepaction Form:Subsurface Sewage Impose]System-Pape 12 of 17 Z I, abed xed dH Zb LZ ME 20 42W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ in system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a pit and four chamber's. Note: Old 1000 Gal. Pit tied into D Box. Pit at 31"below grade w/6"water. Newer leaching four infiltrators w/3'stone. Camera out to chambers.Wet bottom, clean walls. No sign of over loading or solid carry over or holding water. 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.doc•rev.6!16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13of 17 £6 abed xe:l dH £b:2 860Z ZO XeW Commonwealth of Massachusetts Title 5 Officiat Inspection Form r l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments i.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 sol ds Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins.doc-rev.6116 Title 5 Official Inspedior Form:Subsurface Sewage Disposal System-Page 14 of 17 t6 abed xP� dH £b:6Z 8602 ZO 42W Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen - Owner Owner's Name Information is required for every Marston Mills MA 02648 4.27-18 page CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins.doc•rev.6116 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 15 of 17 g6 abed xed dH £b:2 ME ZO XeW A �Y CAP' &4k,.m i 3 � f3—! = A1S A-oL= Avg 13 es .'Rlv€ A-3 - )-6 13 -,3 .43 3 33 96 abed xe� dH £b:2 8 M ZO AeW Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ulpll 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is required for every Marston Mills MA 02648 4-27-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells go 48'+ Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: USGS Well You must describe how you established the high ground water elevation: USGS Well48'+. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins.ckx•rev.6115 Title s omcial Inspection Form:Suhsurfece Sewege Disposal System•Page 16 of 17 LI. a5ed xed dH tt,:2 960Z ZO AeW 0 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Captain Baker Road Property Address William Koppen Owner Owner's Name information is Marston Mills MA 0264E 4-27-18 required Pot every i page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 8, 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.doe•rev.6116 rdle 5 Oflidel Inspection Form:Subsuface Sewage Disposal System•Page 17 of 17 g 6 abed xed dH bb:I.Z 8 602 M 42W i No. / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS YeS 01pplifation for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. A-4 (!4PT V"ciZ U Owngr Is Name,Address, Tel 1_Np.�� / IrV f 9_L-1A laC^! Assessor's Map/Parcel I `t"'f' M a4 l I A VI Installer's Name,Address,and Yel.No. Designer's Name,Address,and Tel.No. `A Go beaeat/+t- 1Vb4S4P - Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date -0-A w s Application Approved by Date Y /7 g' Application Disapproved by Date for the following reasons Permit No 04l 1 —A) Date Issued � l 7 No. ! E JL> Fee ` / E THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9pplication for Misposal 6pstent Construction Permit Application for a Permit to Construct( ) Repair A Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 2.14 CAP7 &AKC-R, tD Own is Name,Address,and Tel.No. Assessor's Map/Parcel d (� M� a f vj--v—M INA M Installer's Name,Address,and Yel.No. 508--f4727-927' Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of a Compliance has been issued by this Board of Health. '\ Signe Date t Application Approved by ° Date V J/7/ 8 Application Disapproved by Date for the following reasons . Permit No. Date Issued - - -- - - - -_ - =n„_-_- _-__..: .-- _.: _-- _ • -- - -------------"------- '- - - = = _ THE COMMONWEALTH OF MASSACHUSETTS 1 BARNSTABLE,MASSACHUSETTS t. Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by(2A 6Ge,1bd5c GV71E"I 1SCE7S at- eZ.� (2"Mr Aj A4w4Wt R0 t' tv1 has-been constructed in accordance r .with the provisions of Title 5 and the for Disposal System �l Construction Permit N �-� dated ? �� Td Installer C,4PFLV i D r C- sr--imp9A tge / P,81) Designer N 1A ( #bedrooms Approved design flows ►�� gpd The issuance of this permit shall not be construed as a guarantee that the system wil. tori as design jed. I r) Date 1 h Inspector (i ,^ No. .--- ✓ ♦ — o t Fee 17-5 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at �T 0A P-TA f hJ ?_-Ak z P o ft MA itS'z_b Ns� "4(C.C.S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must p e completed within three years of the date of this pe°rmit. Date �� jj ! Approved by Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is'required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. ImpoWhen filling A. General Information When filling out I ' forms on the computer,use 1. Inspector: only the tab key p to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O>Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 C 2/8/2010 Ins c or's ig r Date _ The system inspector shall submit a copy of this inspection report to the Approving Aut ity(Eleard of Health or DEP)within 30 days of completing this inspection. If the system is a share 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. ////////^//////////��►��' r t5ins•09/08 Title 5 Offcial Inspe n Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The septic system is in proper working order at the present time. 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): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•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 .'' 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 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 El El Area 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 W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 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 I h Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon tank,D-Box ,Leaching pit anf four infiltrators. 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 ears usage d 2008:32,000 g ( y g (gp ))' 2009:1,000 Detail: 2008:87gpd 2009:3gpd 8 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 ^M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 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 W Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" 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 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 4-Infiltrators ❑ 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.): Sandy soil.No signs of hydraulic failure.Pit was dry at time of inspection.Stain line observed up to invert.Infiltrators were dry. 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 tins•01108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 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 r ' Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size 0 [] F� Zoom out J J J J J.J J J DIn V I Ali S V 0 20 Feet Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER f—...inh+00Ar_')O1 f1 Tn..m of Rime+ahlo KAA All rinhfc roconi http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=126044&mapparback= 2/9/2010 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 every page. City/Town 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: Bottom of leaching 50' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how,you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 24 Captain Baker Rd. Property Address Alfred &Jean Popoli Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/8/2010 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 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 24 CAPTAIN BAKER RD. MARSTONS MILLS MAP 126-044 Name of Owner MARTHA URBAN Address of Owner: SAME Date of Inspection: 1/13/00 v �► Name of Inspector:(Please Print)JOHN GRACI l am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)' i Company Name: n/a Mailing Address: n/a Telephone Number: n/a CERTIFICATION STATEMENT 19 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is Needs Furi1submit aluation By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:1/13100 The System Inspector sh a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND MAINTAINING EVERY TWO YEARS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n1a One or more system compcnents 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n& The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Hoard of Health. n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n& 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 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 WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER.IF ANY DETERMINES THAT THE SYSTEM IS 2) SYSTEM WI ( 1 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla-(approximation not valid). 3) OTHER Wa revised 9098 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,Is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-0" Owner: MARTHA URBAN Date of Inspection:1/13100 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)[ X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13100 FLOW CONDITIONS RESIDENTIAL: Design flow:AM g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):2 Total DESIGN flow: IM Number of current residents:2 Garbage grinder(yes or no):MQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no):.J,IQ Water meter readings,if available(last two year's usage(gpd): WA Sump Pump(yes or no): MQ Last date of occupancy: n& COM M ERCIAUINDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: nLA Grease trap present:(yes or no):AQ Industrial Waste Holding Tank present:(yes or no): MQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MO Water meter readings.if available:nla Last date of occupancy: nla OTHER: (Describe) n/a Last date of occupancy: n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):MQ If yes,volume pumped nla gallons Reason for pumping: n(A TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous Inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nla APPROXIMATE AGE of all components,date installed(if known)and source of information: ORIGINAL 1977 WITH A NEW FIELD INSTALLED IN 199B Sewage odors detected when arriving at the site:(yes or no): MQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 BUILDING SEWER: (Locate on site plan) Depth below grade: Z'_6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: 2_ Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) D& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ n& Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: W Scum thickness:Jr- 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: 1E How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: n& Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:ja& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: Wa 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.) D/A revised 9/2/98 Page 7 of 11 f - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Dimensions: n& Capacity: nLa gallons Design flow: n& gallonstday Alarm present: NQ Alarm level:ji&- Alarm in working order:Yes_No_: NQ Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/A I revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: ilia Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: 4-INFULTRATORS leaching galleries,number: ja& leaching trenches,number,length: nLa leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: nla Name of Technology: jiLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT AND LEACH FIELD ARE FUNCTIONING PROPERLY CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: nLa Depth of solids layer: n/a Depth of scum layer. n& Dimensions of cesspool: nla Materials of construction: nta Indication of groundwater: n& Inflow(cesspool must be pumped as part of inspection)nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:nla Dimensions:nla Depth of solids: DLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n1A revised 9/2/98 Page 9 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a A O p c gB a2L revised 9/2198 Page 1.0 of 11 ~ , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 CAPTAIN BAKER RD.MARSTONS MILLS MAP 126-044 Owner: MARTHA URBAN Date of Inspection:1/13/00 NRCS Report name: nla Soil Type: n/a Typical depth to groundwater: n& USGS Date website visited: nLa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep SITE EXAM _ Slope Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 r TOWN OF B . STABLE LOCATION G`"`-- �` SEWAGE # VILLAGE 1 / t ASSEpS�S�OR'S MAP& LOT14?X"'� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /V 0 C J LEACHING FACILITY: (type) y TIV 0-4I"/I'� (size) 7 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 1,e"F/ COMPLIANCE DATE: "" Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exrisi ;. 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 L 82 I M Li No. / %J Iw�W�7v�dYfP`qt Fee THE COMM ONVPEA PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpptication for Migooal *pgtem Construction 3dermit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: CA Locatio Add ess or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_3 Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of epairs or Alterations(Answer when applicable) % L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y t 's Bo rd of al. _ Signed Date Je 3l— Application Approved by Application Disapproved for the following reasons Permit No. L4F' Date Issued .•;,y . .. w^«-.. ,,...-�- e .. ...r. '.-. - -u+..l..r..-a.Si"ir�'.,r•w:r.w,-. ,. ...,+.&*'^ ,aru ,:;'..^^,a - vas+ - .,� .. ..-�..,�.1'6_-;.. t.w:'.i'.„ No. / �/� / a Fee �f vU THE COMMONWEALTH OF MA91ACH SETTS PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for.Migool *potent Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Locatio�--� a Add ss or Lot No. Owner's Name,Address and Tel.No. �s /V 5 I/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil = t Natgre of a airs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance-with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Cerp"fi- cate of Compliance has been issued y t 's Bo d o/iRli . Signed 0 ` Date Application Approved by Application Disapproved for the following reasons Permit No. 79; Date Issued �� 6 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTAB.LE, MASSACHUSETTS Certificate of (Compliance - THIS ISTO C Y at the On-site Sewage Disposal System installed( )or re-xjaired/re aced by ✓'^-r for as 7WSST' has been constructed in acco dame with the provisions of Title 5 and the for Disposal System Construction Permit No. dated :F^1" Use of this system is conditioned on compliance with the provisions set forth below: Y No. Pe — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wigpogar *pgtem Cot gtrurtion Permit P oe 4f Permission is hereby granted to to construct( )repair( Lya1't`On-si a Sewage System located at 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. All construction must be completed within two years of the date below. Date: ApprovedG%C a i8r 71- .._. t §` } THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 b� Appliratinn -fur 43itipuiittl Worbi Tomitrnrtion Vanift Application is hereby'made for Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: A� p�y _-_4:Ff`,1151.......t4? l �--------------- 1!4'.?' �E!/�F�------ Loc lion-Address - or Lot No. l-................................. ......... L� 1 .....__ .r_ a �7_._.. Owner Address / r Installer Ad ess T UType of Building Size Lot....v7.Y_4 -----Sq. feet ►-� Dwelling—No. of Bedrooms._.__.._. _--------------------__--Expansion Attic (4f®) Garbage Grinder (qJo) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other,fixtures ----- ---------------•-------- W Design Flow............ ....................gallons per person per day. Total daily flow.........o?Q®__._..................gallon s. W Septic Tank—Liquid capacitye-Oft Length---------------- Width_.... ......... Diameter................ Depth-------------- -.;...:.. x Disposal Trench—No.........__.4...... Width................. T,�tal Length-------------------. Total leaching area--------------------sq. ft. 3 Seepage Pit No......./----------- Diameter__.G��___. D�pt belo�` inlet.................... Total leaching area------.------------sq. ft. Z Other Distribution box ( ► Dosing tank ( ) d,(� 1'") . — 3— ,31—7 7 Percolation Test Results / Performed bY.......................................................................... Date--------------------------------------- W Test Pit No. 1................minutes per inch Depth of "hest Pit.................... Depth to ground water-------.-----._--.--._.. �14 Test Pit No. 2................minutes per inch Depth of Test Pit..---_-_..__.__-___- Depth to ground water--.--.---__----------__. 9 ----------------- ----------- --- ---- O u_ - ---- ----- ------ Description Description of Soil-----19 l ?.�t�-12 _ _d- ra.- �vikv ---`l�_-...�`' '` t�, - x W UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------.._.----------------.-..------.----------- ---------------------------------------------------------------------------------------------------------------------- . --------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the'system in operation until a Certificate of Compliance.has been is ed by the boar ofLh ��/th .�Sig d ---- $-'------- _.- ' Date Application Approved B J ---�-• ---Date---�-----•- Application Disapproved for the following reasons-........................................... ---•--------------------------------------------------------------•. •-••••••••---•---•----•••-••••--••--•----•--•----•--•------••-------•---•••-••---•---•-------•-•------------------------------------------------------------------------------------------------------- Date PermitNo........................................................ Issued........................................................ Date ••••.•••••�••••.a•yw••••••••••+•o•.••••:,•••w••c•r••.•••••••a•••w••a.,••••w••••••••••••••a•••••�•+sa••«•••e•••••u•••.••u•ia•••s THE COMMONWEALTH OF MASSACHUSETTS BOARD On HEALTH 4 Iertifiratr of 01111intplianrr HI YTS TO CERT V, hat he In idual Sewage Disposal System constructed (Z<or Repaired ( ) by.......---- . LLLt _ tallf r has been installed in accordance with the provisions of Article XI of The State nitary Code as described-4the application for Disposal Works Construction Permit No.:--------------------------------------- dated----5:.._' s__.______. .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector---------------------------------- ............................................ .. y " Nu:........... ` ,�� j ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH App irtttion -fur dips ttl Wvr4ii Towitrurtion Vrrm t Application is hereby'made for a Permit to Construct ( ) or Repair ( ) 'an Individual Sewage Disposal Syste�mf at ................ s.�fiJyr�r�+1 .1.r. , i /" . ,ram Loc tion•Address / or Lot No Owner el' Ad ress orw -•••-------•--•----•- • &I t .......... Installer Ad ess UType of Building Size Lot.... ....Sq. feet Dwelling—No. of Bedrooms---------a ________________________.---Expansion Attic (/fib) Garbage Grinder 040) Other—Type of Building ___________________________ No. of persons_______._.________________- Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- - - W Design Flow............." .....................gallons per person per day. Total daily flow.........O +d......................gallons. 9 Septic Tank—Liquid capacityo-090.gallons Length ............... Width............... Diameter _ Depth .-_..- xDisposal Trench—No.-.-------------------- Width.... �S al Length-------------------- Total leaching area....................sq, ft. Seepage Pit No.._.... .�. Diameter/'+ -_-_ D'eptbelo inlet_________ _________ Total aeacli'ing area ..____.sq. ft. Other Distribution box Dosin 'tank ( ) g 3- 3�-677 Percolation Test Results Performed by:_..............%------------------------------------------------------------ Date--------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground wati'r.::,__..-__-_.--.- fs, Test Pit No. 2----------------minutes per inch Depth of Test Pit_.--__--_______-_.-_ Depth to ground water-_.-.--..-_-_---____.-_. . D D Description of Soil `�.?.t��011'ttw�- * � u. -`-�.. i12�.;. t��`iur ' '°".�..' W UNature of Repairs or Alterations—Answer when applicable---------------------:------------------------------------------------------- ------------------------------------------------•-•----------------- .....................................--------------------- ----- 'k ---------------------------------------------- Agreement: .. ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beii , by the boa of h alth. Si -• .- Date Application Approved BY •-- ---------------------- c7 Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------- •--•••••---- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•-•--------- . F Date Permit No......................... ...................=---------- Issued. Date l -• THE COMMONWEALTH OF MASSACHUSETTS BOARD O H'EALTH . ...O F7�F. • err# uc tr of Tompliaurr T HI S T�0 CE�RT. the In rdual Sewage Disposals System constructed (�or Repairedby� ( )THI S TO CERT. ha t/ � r I stall s at e,ccordan -- ---------------•--••-•----••--•---••---•---•-•-----•••- has been installed in ce with the provisions of : rticle : 11 f The,.State ,nitary Code as descr�e�}'n the application for Disposal Works Construction Permit No'..__._._..__ ':_-_-._.-_.-__ dated "'._'*25'. ____/_____________ THE ISSUANCE OF TH S CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE.THAT THE SYSTENI-.:VJILL •FUNCTION SATISFACTORY. r u DATE............. ------- / = Inspector THE COMMONWEALTH OF.,M,ASSACHUSETTS t BOARD 9F HEALTH :. . . .......OF....... ... .......................................... No._____._ FEE-- �i� >Q�ttl lark, �• tr rti �rrmit --• Permission,i�hereby granted--�----- --.� - -- ---------------------------------------------- ----------------- to Constrp ;) or epai ,(` ). n I vidua, e a ;e Dis ystem at '- Street as shown omthe application for Disposal Works Construction Pe No. ........ . . - Bo- - - ard Healt - - ---••--•---•-•� DATE......... ------------------------------------------------ FORM 1255 Hoses &,WARREN• INC.. PUBLISHERS' 1 _ 77 Two' N �o t 27 T. D 0 - r a �ravtv_- IV 4 PtAN #ECQRAtp 04 rE' tor E tirr rw �-ar ,y£ k-ou y oc�rIoN . S ' .. Y'xrs pt .AI►' /s a ocC:ArEo am D, VNp �A.5 sN d� v " Ar£R£o l 'AA L& o N f o io m x O fM �ti �j1t Oi.M 8ll t C�fSAI t ,S ExT 0 A,C AC AP co U'l R "� / W is .O F. g° GEC �c ..l":!0=,WJ �r p ,tts't5'k� - + .. ,� Q Low,o. f IST AAW p t7,4 1y: . 't!.A R M`4 L�.N. A A'ssa r. {. SURv � Y,r • a