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HomeMy WebLinkAbout0057 CARLISLE DRIVE - Health 57 CARLISLE DRIVE MARSTONS MILLS A= 122 - 137 Commonwealth of Massachusetts Title 5 Official inspection For Subsurface Sewage � m ge Disposal System Form - Not for Voluntary Assessments ca Property Aciaress l�J Owner �©✓1 a /C� s e I 1 -� Owner's Name information is required for every Page City/Town (Gil 1 I S ��111I State Zip Code Date of Ins edion Inspection results must be submitted on this form. Inspection fonns ma no way. Please see completeness checklist at the end of the form. y t be altered in any Important:When filling out forms A. General Information on the computer, / 1 use only the tab 1. Inspector: ' key to move your cursor-do not use the return Cr ✓Gt� o/ram//1 key. Name of inspector— �J Company Name Company Address Citylrown LS�� - State Zip Code Telephone Nurhfw I% License Number B. Certification I certify that I have personally inspect$d 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 DEO approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The systeni: Passes i ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority °�/Z��'` Inspectors ignature Z� Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional ol;fice of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. wa• ! This report only describes conditllions 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 6f use. 15ins• I I110 Ftw 5 Clfcfal Inspemon Form Suhswiace Sewage Disposal Sy,em•Gage 1 nl 17 Commonwealth of Massacf usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners Name information is i required for every OS 'e,4" vl A/, oa bjZt page. City/Town State Zip Code Date of Inspecti n B. Certification (cont.) Inspection Summary: Check A,I'B,C,D or E/always complete all of Section D i A) System Passes: f �-I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 316 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system compon6nts 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. i 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 ❑ Nb(Explain below): i !Sins•11110 n143 5 rnr64 i„S,�aM„Fnrm .^.^>ubsurlacy Sev�9e Disposal System Page 2 0(17 i i Commonwealth of Massachusetts y =- Title 5 Official llnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address a-e. � Owner Owners Name ✓`information is OS vvf ii��/ Oa b✓� required for every page. City/Town State Zip Code Date of Ins ion B. Certification (cont.) B) System Conditionally Pas§es (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): i 1 ❑ 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 reiiilaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removetl ❑ 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 Oublic health, safety or the environment. 1. System will pass unless oard of Health determines In accordance with 310 CMR 15.303(1)(b)that the system it not functioning In a manner which will protect public health, safety and the environment: ' Cesspool or privy is withiin 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 'Sins•11/10 - Iltle 5 Official Inspection Form Sutxwiace Sevage Disposal System•Page 3 or 17 Commonwealth of Massachusetts Titre 5 Official Inspection Form _— Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i Property Address o1G 1 �l Owner Owner's Name �02 information is / required for every (' � page. n own State Zip Code Date of lnspecti B. Certification (cunt.) 2. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the syster6 is functioning In a manner that protects the public health, safety and environment: i ❑ 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 su�ply 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 j i f f 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 ❑ ❑i Discharge or Ponding of effluent to the surface of the ground or surface waters due to an ovehoaded 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 V2 day flow :Sins•11/to T"1W 5 trial 1—pedion Form:SlIbm—face Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Tithe 5 Official n!&ection dorm Subsurface Sewage Disposal Syte - Not for Voluntary Assessments Property Address Owner information is Owner's Name required for every page. City/Town State Zip Code Date of Inspe ion i3. 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: ❑ L�J Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portioA! of cesspool or privy is within 100 feet of a surface water supply or —/ tributary to a surface water supply. ElL� Any portion of a p or cesspool pri vy vy 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 It at no other failure criteria are triggered.A copy of the analysis and chain tf custody must be attached to this form.] ❑ The systemf is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 0/ The system falls. 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 own�ser should contact the Board of Health to determine what will be necessary tb correct the failure. i 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 ll of a public water supply well If you have answered "yes" to any uestion 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 CMIR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•1 i/lo ' idle 5 Official Inspection Foam:Suhswiare Savage Disposal SyUem•Page 5 0l 17 Commonwealth of Massachl'usetts _- Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments kc 4? Property Address Owner Owner's Name S Il information is � v/ /�� Q�required for every 7� ; page. City/Town j State Zip Code Date of Insp on C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No El Pumping information was provided by the owner, occupant, or Board of Health �,/ El ET-' Were any of,the system components pumped out in the previous two weeks? ❑ Lg' Has the system received normal flows in the previous two week period? ❑ Q/ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available not6 as N/A) Was the faciiity or dwelling inspected for signs of sewage back up? P ❑ Was the site!,inspected for signs of break out? I-� Were all system components, excluding the SAS, located on site? ❑ Were the se itic 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? �0 Was the facili�y owner(and occupants if different from owner)provided with information op the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined ed based on: �7 L! Existing inform ation. For example, a plan at the Board of Health. L� u Determined in'the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 115.203 (for example: 110 gpd x#of bedrooms): 22 0 i l5ins•11i10 rills 5 Olfirial Inspe0k)n Form:So6surfw'e Sev�ge Disposal Syslem•P19e 6 o!17 i Commonwealth of Massact usetts _ 04 Tithe 5 Official Ilnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner information is Owner's Name OSvV//k required for every 5 page. City/Town State Lip Code Date of Inspection D. System information Description: d Number of current residents: o Does residence have a garbage' i grinder? ❑ Yes No Is laundry on a separate sewagelsystem?[if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if availabi4(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gs) i 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: �sns• 1 vfo ------ �Ife 5[Nfirial Insoedirn Forrn:Subsurface Sa_age Disposal System Page 7(X 17 Commonwealth of Massachlusetts Title 5 Official Inspection Form _ f = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v.y J Property Address Owner Owner's Name information isQd 6 SJ� required for every i /5`— ,�-- page. City/Town State Zip Code Date of Ins ion D. System Information (dont.) Last date of occupancy/use: Date Other(describe below): i 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, disth6ution box, soil absorption on system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy i ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach 6 copy of the DEP approval. ❑ Other(describe): Isis•1 vto rte 5 Offival Inspedirm Form-Sut>surince Sage Oisposet System•P1ge 8 a 17 I Commonwealth of Massachiusetts Title 5 Official Ihspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '�-s• C� CG��fs� / Property Address Owner Owner's Name / information is r/C�- required for every nO 6 53� q page. C1tylTovm State Zip Code Date of I pe on 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: /� feet Material of constructi�40 El cast iron PVC ❑other(explain): / Distance from private water supply well or suction line: feet Comments (on condition of joints; venting, evidence of leakage, etc.): 'i Septic Tank(locate on site plan):; Depth below grade: C� feet Material onstruction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: L5 X i Sludge depth: ' 1sin5.11,10 ----- ❑IIe 5 Otfiriai Inspection Form:SU1)Sulfare Se"age OisPosel SySlom•Page 9 o!17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sy4tem Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is /� required for every �c Ae ; /'"/� 6 J57 Page. Citylrown { State Zip Code Date of Inspe ion D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle �/ T Scum thickness Distance from top of scum to toplof outlet tee or baffle Distance from bottom of scum tolbottom of outlet tee or baffle How were dimensions determine) ? PL? �G Czy/c�_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ff I 01 n 1 G v� CJ•.Y / CS l✓1 t�l� CO v C c , Grease Trap (locate on site plan): Depth below grade: Feet Material of construction: I ❑concrete Cl metal I fiberglass ❑polyethylene ❑other(explain): i Dimensions: 1 Scum thickness I Distance from top of scum to top ofloutlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: ---- --- ----- 151ns•11/,0 Date r"e 5 Orr'"al Inspection Form;Subsurface Sevage Disposal System•Page 10 of 17 i i j Commonwealth of Massachiusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Disposal System Form - Not for Voluntary Assessments Property Address ,n I Ownerinformation is Owner's Name rJ required for every �f�' ! l� �v�j� (,�6 page. cityfrown i State Zip Code Date of Inspect on D. System Information (dont.) Comments(on pumping recomrr}endations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet ihtvert, evidence of leakage, etc.): 1 t i i i Tight or Holding Tank(tank mu9t 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 i Date of last pumping: { Date Comments (condition of alarm and float switches, etc.): f i i I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins-imo Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 17 i Commonwealth of Massachusetts Title 5 Official Ihspection Form Subsurface Sewage Disposal Sysitem Form - Not for Voluntary Assessments Property Address informOwner Owner's Name equine for is (7 S I _� required for every (/ `Ff' G� � l page. City/Town State Zip Code Date of Inspedi n D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert ZV-et-7 Comments (note if box is level a�d distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 4-f 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) (ldcate on site plan, excavation not required): If SAS not located, explain why: , 5 GNcrd inspragion Forms 51'bsur"8 S"ge DisPosal System•Page 12 of 17 i Commonwealth of Ma sacliusetts Title 5 Official Ilnspection Form Y= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is O� required for every page. City/Town State Zip Code Date of Fnspettion D. System Information (cont.) Type: Ex,d leaching pits numbe ❑ leaching chamber number. ❑ leaching galleriesi, number. i ❑ leaching trenchesi number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspools number. ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,;signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer i Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ ❑,sins•t Ir10 Yes No r'1�5 OfficiiA InsW.ction Fnrm Subsurface Sege Disposal System•Pnye 13 0l 17 Commonwealth of Massachusetts 01 Title 5 Official Ifnspection Form Subsurface Sewage Disposal Sy�tem Form - Not for Voluntary Assessments S2 Property Address f Owner Owner's Name I information is required for every page. City/Town State Zip Code Date of Ins ion I D. System Information (font.) 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.): i i i t5ins•11,10 'It"5 Cfficral Inspection Form;Subsurface Sewage Disposal System•Page 14 of I i Commonwealth of Massachusetts Tithe 5 Official Ilnspection Form osal Dlsa S Subsurface Sewage p Y l m Form - Not for Voluntary Assessments s Property Address Owner Owner's Name A information is required for every page. City/Town State Zip Code Date of IntpecKon 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 pu is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately] Q/� 1 � a 15ins 1 Vto r•I!e 5(Xicial lnspedion F.," Subsurface Sevnge Disposal Sy;fem Page 15 0l 17 i Commonwealth of Massachlusetts -= Tithe 5 Official lhspection Form - - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date�Otlns on D. System Information (cont.) Site Exam: ❑ Check Slope — ❑ Surface water �o f� ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. feet Please indicate all methods usedito 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) l� Checked with local Bbard of He alth explain: ❑ Checked with local eXcavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: I / g al -7 C Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•11/10 Tfle 5 Vidal Insoeainn Fo":Sutxurface Seymge Disposal System•Paye 16,)(17 Commonwealth of Massachusetts Title 5 Official Inspection Form -1 s Subsurface Sewage Disposal Systlem Form - Not for Voluntary Assessments n Property Address Owner Owner's Name equineinform Lion is /l7� ✓�� � i �02 to required for every l/ S �J page. City/Town State Zip Code Date of I nspe&ion i E. Report Completeness!Checklist Inspection Summary: A, B, C', D, or E checked RInspection Summary D (System Failure Criteria Applicable to All Systems) completed Vtem'Information— Estimaied depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file j 15ins•11/10 fille 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 f, , TOWN OF BARNSTABLE LOCATION S �I Cis-��� `�� e �(�, SEWAGE 1� VILLAGE 0�1 �\S • �, ASSESSOR'S MAP & LOT j a— I3-7 4j77._3Sq INSTALLER'S NAME PHONE N `— L _w SEPTIC TANK CAPACITY 100 CD LEACHING FACILITY:(type) L e P: (size) C) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER' DATE PERMIT ISSUED: I DATE COMPLIANCE ISSUED: -° VARIANCE GRANTED: Yes No ,a �►�� 1000 GA , 1 .. 1y A090"NR0R8 MAPN No...T -.1.03 �...............�® .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diti-puuttl Warlai Tomitrurtiurt rantit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System a .............� ............................ s ... �=-_... 1-° _ . ---•-- ............Lo 4ddress or Lo No. j�Owner K------------------ .,�_7------ .........�� 1 Address ,�n .A W ----------L� G4� �. .`P-L ..................................' . ----------L 1�-- .._Y`�1 � `'u �- - -- Installer Address Type of Building Size Lot............................Sq. feet — No. of Bedrooms. ....... _______._Dwelling .................... _ ---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons..................._-------- Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow.........................___................gallons. WSeptic Tank—Liquid capacity___.__._-.-gallons Length________________ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-----_..............sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.-.--.--..__________ Depth to ground water........................ f? Test Pit No. 2................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................ a -------------................................................................................................................................................ O Description of Soil................................ ... . V .................................................... ------------------------------------------------------------------------------------------------------------------------------------------------- ..........t V Nature of Repairs or Alt ations F2��sN er when applicable.....................;x,--5 ..�.._1_......_...N` .e.�..._......... ---------------I.D. .�-----------�- ------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ ental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli nc has bjerl issued y the b and of ealth. Signed ---- -- --- ..---... --------------------- ---- ..S Da q Application.Approved By -- - off. . . .L.. Dale Application Disapproved for the following reafonr- ------------ ---- -------------------------------------------------------------------------------------------- ----c�- -- ... ...... ...... ................................. ... ...................................................................................... -------a....7.��' `.�- Dace Permit No. .. — I D ----...--- Issued --------- ^............... ....... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 'HEALTH TOWN OF BARNSTABLE Appliratiou for Divi-puiittl Work.6 Tomitrurtiurt rat uif Application is hereby made for a Permit to Construct ( ) or Rcpair-({-._� an Individual Sewage Disposal System a ' c 1 .... ' -- ••-•...... Lv�1l ad/d{r'ess or Iola Napo. • 11 Owner 0 Address ...................... Installer Address Type of Building Size Lot............................Sq. feet -S Dwelling— No. of Bedrooms_______________________________________----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons----_---_---_-_------.-.-. Showers ( ) — Cafeteria ( ) dOther fixtures _----------------------- ----------------------------._..-------------------•---------- ---------------••-••......................-••-•........••---- W Design Flow............................................gallons per person per day. Total daily flow.-------------------------------------------gallons. WSeptic Tank—Liquid capacitv------------gallons Length---------------- Width................ Diameter___.._..--.-_ Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No----------- - ------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ ;, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ tx ....---•-•------------------••••••••••••••-•-••--••-......-••--••-•••............••......................................................................... O ------------ U Description o Soil.................... .................•-� ................. ---•- --------------------- ------------------------------------------------------------------------------------------------------ --------••--'---- - --------- U Nature of Repairs or Alt ations r�sx r when applicable..................__ _�. .�... -----..-----�.. .................... Y.f�.Q o ........---t ................•••••---••-•-••-•-----------------••--•-------------•--•-......----••--•••--•-•••-••---.................-- t 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 CompliL c) has bye issued by the bLardof health.Signed ... ._..:....._............. ....... ........ �.......... 5 Dare, _ Application.Approved By --------- -<`" . -� -.-.. - - ....................... .-----� r J-72 S V � �� �� Dace Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------- ------------- ---------........_...--------------------------------------------------------.........--..................-----..........-..-------------------------------.._.--...----.-...........-------- ------ Permit No. � � , Dare .7-_-_------ .�1 C� �...... ....- Issued - �........... .. /.5....................... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Terlifirate of Cora tianre THIS IS�Q CERTIFYt That the Individual Sewa e Disposal ,ystem constructed ( ) or Repaired�_" ) by ------- .. ... :- -�.. -5-- -----------------..--------. In,nicer flit ..` C' c t--� _R- -----------�- ----------------- ... ... ......... ------ 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. -..------9..,S7--------f n_. dated . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.. , / -.` '. `2 DATE..._ Ins ecto� �" ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �0 TOWN OF BARNSTABLE (� Cq(D No.... ar..•-•. FEE........................ a�u#r�rtua�rrnti� � Permission is hereby granted C:C \ �"` - �".� -�-`---•-- to Construct ( )off'fR, pair t_-�n Individual Sewage Disposal Syst�j n N to^ � (/ at No..................... ---......... �� ..._I_.� - ------. _... ► �'1 ........................1 � Street / CC�� as shown on the application for Disposal Works Construction Permit No.-_._,?�(-�__ Dated-----�..7-..1..2.,S.......... S Board d of Health DATE----------------------•--•-•---.--.- --•-•-•--•-----------•-------------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS 67 LOCATION SEW GE . P ItITNO. VILLAGE r INSTA LLER'S NAME i ADDRESS � hm -12 8-S'a-u a BUILDER OR OWNER A f l ® cD/vs-re 0 c w/ DATE PERMIT I S S U D DATE COMPLIANCE ISSUED 1 • 1 L-A R�. ,� a • i eat VZV, THE COMMONWEALTH OF MASSACHUSETT� BOARD OF HEALTH 4�Y.M.--......OF........ [-------------------------- . pplirFatilan for Biipu,al. Works Tnnotrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Locatww��--��A ress ---•--•---or-Lot No. •- �.��1?..._..�a ,l_�. ¢.V 5.:..._... •.............•-------•-•_----- .......°.••••-----............_........._........... ner a Address ................... ---•............................Q h.. ... 1�'� /=�_:. 1..---•--...... -•--.....-- Installer Address d Type of Building Size Lot_ fed-2------ sq. fe t , U Dwelling—No. of Bedrooms-_. __________________________________Expansion Attic ( ) Garage Grinder ) Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures ---------------------------------------------- d Design Flow...................... ... gallons per person per day. Total daily flow.._......4 Q..:...•..................gallons. WSeptic Tank—Liquid capacity.�� .Q.gallons Length___,D Width...Y__....__ Diameter________________ Depth.. ............ x Disposal Trench=No..................... Width.................... Total Length_................`Total leaching area-----.. ....sq. ft. Seepage Pit No..•--..1 .---•• Diameter...K.... Depth below inlet--_:*rr Total c area ft. / P . - •• q Z Other Distribution box ( ) Dosing to Percolation Test Result Performed by ! __...... �._j,�l_ i!l.iz.. ....... Date._1_'Q_-�.�":7 ':....... -- Test Pit No. 1..._ �Z.......minutes per inch Depth of Test Pit...............:.... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------- --- r, ._..........___ 0 1--- Description of Soil..............�_-. _, 1� .. �._ -� - --`---- •- � --------..A._._.......Via--_ �_..-...•:- ._�---------------------------- �., ...-- x •--•-••-•--••------------ -- .....•---.....•••••-•-.._...... 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 LITi.;;:, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in r operation until a Certificate of Compliance has been issued by the board of h lth. r S ----•----ign , . Application Approved By...... ��G . .. _.C�l✓._t� ...... .................•-- ------�-9-.-- . a...... 16e�/� Date Application Disapproved for the following reasons:................................................................................................................ ..............................•-•--•-•--......_.._...---•.....-•••-•••••••----•--•---..........----•-•._.._..._...........-••---•--•--••----•--•---•-•••--------••--•---•••-•---•--------•-•-•••••-•-•--- Date PermitNo......................................................... Date" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ rG4 '}.........OF........, I........... Appliratton for DiapnsFal Workii Tnnitrnrtinn Vautit Application is hereby made+for a°(Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System/a�t�j: Jjy(g_ ���rr.. " //�}}�` .--......46r- ` rF1'.!.�.�.l,r. .hc:._..CC..I.`C.. 'ry .... ...............�. .'.. '_'.".'."., Loca' A ress or Lot No. .e.: ------ --------------•--- canerAddress.....---•------------ -�'.? - - t&.4t............. ..................................................................•-------------------------...--- Installer Address Type of Building Size Lot.r�� a .2......Sq.,f t Dwelling—No. of Bedrooms---c ' ................................Expansion Attic ( ) Garbage Grinder 7W aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other .fixiures .................. ------- er person per day. Total daily flow.._...3.4 Q_..................__......gallons. WSeptic Tank—Liquid capacitytip,-gallons Length.._:..__..___ Width...ly......... Diameter................ Depth.,$........... Disposal Trench—No. .................... Width..............._.... Total Length.................... Total leaching area..... _ s ft. Seepage Pit No.......le.......... Diameter... Depth belowinlet._ iar.KTotal,I c�i area.- .."�„'q. ft. Z Other Distribution box ( ) Dosing t * - aPercolation Test Resul� Performed by !!M . ....... ...... ....... Test Pit No. 1.X_,, ._...minutes per inch Depth of Test Pit:................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch,,.: 'Depth of Test Pit..............:..... Depth to ground water......................... a+ ..................... J3 ��,� 3 4............................ O Description of Soil............. " " `�' -' •. "' j A . ��Gf t '�d �!"� ----------------------- --- tJ -_.._.• _._......_-••--•-•:................:.............. = • •----•----•------------------------••-----_--.------••----••---------•-•--------•------•------...---•---------•--.-•---- U Nature of Repairs or Alterations.—Answer when.applicable........:......:..........................:.................................................... -•-•--------------------------•----•............... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T'L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. \ e Sign ,- --•- .. •...................•---- r" Dat Application Approved BY e�4 `. .:....... •� Date Application Disapproved for the following reasons___________________________ _ ........ ..........................................................-.............................................................................................................................................. "j" Date PermitNo.......................................................... Issued--------...--= n� --•--......----------.... c.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH 1 .......... OF............ ..4..... ...>...................... .............. Zrrtif iratr of Toutplitanrr c T Disposal System constructed ( �or Repaired ( ) by--- �IS IS TO G• T��Y , a the Individual Sewage ,----•------•--••------._...-•----'---•---••....... .................................. ��((/ � �/ I nstller a / .. at 1i .. "!G✓ , e!,r3 t tom` �d G� � "'�� — • ': '�'.� :+------------- has been installed in accordance with the provisions of T 5,of The State Sanitary Code as described in the application for Disposal Works Co� � ��� PP P nstruction Permit �o - ---------- -- -••---- ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE.CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rry; Q / ..........OF......... .......................... FEE.- .... NO ......... Dispos a or3- A-1 �o .r rndt att rrntit Permission is herebyranted.... '. to G}onstr t*( /,r pai ( ) a ndi e ispo ,yltem � at No.� JI! .... t 1'� 1 . ......... -- ................ Street qq�� as shown on the application for Disposal Works Construction ;rnf No.. ri.... ated.. "1.............................. y Board o . eal�•. DATE........ --•--•---......-•....................:...........• ; FORM 1255 HOBBS & WARREN, INC., PUBLISHERS S it c .h - 5�+..i�t� i AO GAtZBAG� GQl SEPt�I c `T"at i►� = 330.E tSc % _ 4-9 5 6.P D. - us4r=- I o00 Co -''►r,a�;' .�15Po5At- PIT - USE. loon ALL AIZE.A = l5o ISo SF �c 2.S = FiQT'7't7lNl ,C1,QEA c C� 5T'. r t TOTAL 'T,>GSl6Q = 42S K 330 CO Fgt> � 0 t� Pt�lZGDL-0TIOQ tF&TE tQ 2_Atlu 02 LX--%. Peo p raaRl � p t i I C-xi,44 G.=�B t 4. 7lTiCa /�nR TJ77CC.iii r i... P"Pa S tUl{..+ ,np� 4 r' bBox ts� Goo G'Q 4u Z aG�LI LsArc 4 A J� PST �t� • Wtr�.I �� WAS1•Ilit> 5'roN� D,J i CEQTtF1ED PLc--r F't,•,t ji - r LOCATlot.J 0e3rSp—,\//C.t. k•!cs �c n.t..E=- C.A L (k do Tez— :�1 "40 ,SAT l G�tzrlP�{ T►-!AT' T{-1E. pu13-OATtDtJ 51.loviQ Pk. Aki lzGp Re1'.iGEw G(->AAPLVlG WIT" TWG: 5tp�_t_1►-�t= �' AWE=> SGTt3ACIG G'C-quiQE✓Ntc:t-tTs OF •t "C �D-f- 4?L- TOWw r -SlAaKi sLa tZEGtS't'�iZ�D t�t..tl;> 5U2vEYocZS TI-11-S FLAW IS LJOT t?3A�,t='p U4-.� AN QSTEfL�/1LLF= o / (ASS. I#-45 ZM AAC-NT SU��/t_�{ ^(l�(; i3Ft=S I"�, �illolatLl� 1��P1 1CA.ti !"T'_ ti,br E3C uSC0 Tc> I7r-.-_1 C '_Mtti�l=- �T l_II.tC_ Ot`_,r AK.t_...I-.l t_.L QC Garrbar� �rzt�� 'Ddl L.,r >~Low i t b x 3 = �'�O G•Rb. -- .�. 'SEP'T'I C `r'1S+J K = �30,r IS C % * d_q Cj 6.R D. 12 S So j� �• T �r C.1 ryE' 1 CbQC> Ei.Q L. N G V r2' �71 PvSAL PtT - �sE toc>c� Gn_L_. ic�v SF 2.5 TOT,&L -DESIGIJ = .4-25 6.P..LD. ToTo L t� do J ; Pt;J:2G'DL6,TIoL1 Z&Tf~ -/. i rasr+c4p/, �CIl.L YoP Fun +�ao.o 4. X7 7�04t6 4 ( DKr. wv "Box �PP9SGlu.v. T�c/oa aQoLK. I9MGl.•$ !:+r1 ►Uy,` 1��G I o G,a�.. iG Z '•• / LsAcN PIT tu! w r�.t A 1�Jg/4'���Z WAS+•1ED CE2Tt�tEl7 Pl,raT Pt d.4.1 4L f LvGA1'i otJ � r -SCAL •}-o N p FIAT --- . �, %T� '�.;�'! , �^� ti� •d i�•i~11 ( GisWTtr- T34A-r TI-tG. UWI)ATtDki 5Now►J Atom! �Z t='i_tZcL.10E "t-2MMIJ G0,VIPL.-eG WI'TA TWZ; 'SIDEL.IWC ,�+yd,u t7 SE`'t't3�GV �"G-p U t�E Nt c I.,t-fc, ©� T►�� �--O`t' �-Z. J�l PL S-24, VAT G .T, (-t �—) B A.XTG P, 4-, W 4eE= t2E6(S•M tZ>rD t-Ab wG SU V YoctS Tt-115 PLAW IS LIoT PIASGID 064 AW 05TEIZV% .LC� ttJS("t?:1.CAElJT �Uf'�/ �{ �ttlC c;r=r=5�-r�i 7140Wl.D �1DT' E3� lJ�,�� i"U t�r 1'r•L M t��r- Ln T L_I N t;�.a G �a `` t Commonwealth of Massachusetts rm r, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Carlisle Dr ' Property Address Y �t John Nilson .a Owner Owners Name information is , required for every Marston Mills i" MA 02655 10-15-2018 -, page. City/Town State Zip Code Date of Inspection r.r'I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 14- 3gCQ on the computer, Darrell Stone use only the tab key to move your Name of Inspector cursor-do not Cape Cod Septic Inspection use the return Company Name key. P.O. Box 1466 rab Company Address Harwich MA 02645 City/Town State Zip Code r�ua 508-240-2500 S14995 Telephone Number License Number B. Certification certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Condition asses 3. ,❑ Needs urth r Evaluation by the cal Approvin I y 4. ❑ Fails 10-19-2018 Insp ors Sig re Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �m - ,9 Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State. Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System 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: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND�(Explain below): t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 3 ,IP Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments %! 57 Carlisle Dr Property Address John Nilson Owner Owner's.Name information ati is every Marston Mills required for eve MA 02655 10-15-2018 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 'Obstruction is removed ❑ Y -❑'N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form '~ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ;5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts (P Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments `............e 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date oflnspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- ER10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts a Title 5 official Inspection Form ' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Z 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)] i5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 P 9 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form ' i Subsurface Sewage Disposal System Form Not for Voluntary Assessments i 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is Marston Mills required for every MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NSA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 2 bedroom residential dwelling Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-2-2018 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts g Title 5 official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - � 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 16.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts l Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection De System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank, D-box, Pit#2 unknown; Pit#1 1995 per Board of Health Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1 T"+/- 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.): Apparent good condition t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments f 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11" Depth below grade:' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 11" Distance from top of sludge to bottom of outlet tee or baffle 21" 0,1 Scum thickness 6-1Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Sch 40 outlet tee Recommended next maintenance pumping within 1 year Recommended maintenance pumping every 2-3 years 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts - (P Title 5 official Inspection Form - 11. Subsurface Sewage Disposal System Form'- Not for Voluntary Assessments 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information equir for is every Marston Mills required for eve MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap ('locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal i❑ ❑ fiberglass lasspolyethylene 9 ❑ El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts p Title 5 official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vic,, 57 Carlisle Dr Property Address John Nilson Owner Owners Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Grade to box 20" 2 outlets with equal flow OK condition Normal liquid level No sign of leakage No scum No sign of failure t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 57 Carlisle Dr Property Address John Nilson Owner Owner's Name required for is every Marston Mills required for eve MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Carlisle Dr v- Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of pondingi damp soil, condition of vegetation, etc.): Pit#1 Grade to pit 57" Cover 16" Bottom 135" 11" of water in the bottom Staining @ 18" from top No sign of hydraulic failure Pit#2 Grade to pit 17" Bottom 97 Previously backed up Dry No sign of hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is Marston Mills required for every MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids. Comments (no; condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \ � 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection D. System Information. (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately s EA_1jT �i I I � U4 S .-(D P1 p#a A B sL'i yid 38 - 4 Ili 4,?- 1 6 16insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments d � 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 15. Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 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: See below You must describe how you established the high ground water elevation: Elevations from USGS maps are approximate Property ELV. 57.0 Bottom of SAS#1 ELV. 45.75 Bottom of SAS#2 ELV. 48.92 GW ELV. 25.0. Separation >4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts l�? Title 5 Official Inspection Form b), Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Carlisle Dr Property Address John Nilson Owner Owner's Name information is required for every Marston Mills MA 02655 10-15-2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18