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0010 CHERRYWOOD LANE - Health
10 Cherrywood Lane 1 Marstons Mills P �A 041 012007 t i I ,Sep ..04 2016 13:15 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts Title 5 Official Inspection Formrn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tV 10 Cherrywood Lane �= Property Address Matt McCarthy _ Owner Owner's Name information is / A required for every Marstons Mills V MA 02648 9-2-16 W page. City/Town state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:out forms A. General Information �`/ ���,/q `� kI1tu11nr ,� fillip aut forms 'T / X �1q on the computer, \����`�� ZH OF MA ii��i, use only the tab 1. Inspector: 0��� �ti' key to move your :' JAMES G cursor-do not lames D.Sears =�' use the return Name of Inspector =v ? key Capewide Enterprises, LLC Company Name 153 Commercial Street ( � 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 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-2-16 spectors 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. 151ns.doc-rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Sep 04 2016 13:15 Jim The Inspector Man 5085349919 page 19 Y. g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 10 Cherrywood Lane Property Address Matt McCarthy _ Owner Owner's Name information is required for every Marstons Mills MA 02648 9-2-16 page. City/Town State Zip Code Date of Inspection Aj 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 system is a 1000 Gal. Tank D Box and pit t B) System Conditionally Passes: .4 ❑ 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 Official Inspection Form:Subsurface Sewage Disposal system Page 2 of 17 Sep 04 2016 13:15 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .10 Cherrywood Lane Property Address Matt McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms 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 ❑ 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. t 1. System will pass unless Board of Health determines in accordance with 310 CMR t 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 15ins.doc-rev.6flS Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Sep 04 2016 13:15 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Cherrywood Lane _ Property Address Matt McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-2-16 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 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 811111�11 is less than 6" below invert or available volume is less than 1%day flow p;T t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsur ace Sewage Disposal System•Page 4 of 17 Sep 04 2016 13:16 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Cherrywood Lane Property Address Matt McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-2-16 page. Cityfrown 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 16,000 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 11 of a public water supply well t 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.doc•rev.6116 Title 5 Official.Inspection Form:Subsurfsoe Sewage Disposal Systam•Page 5 of 17 Sep 04 2016 13:16 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherrywood Lane Property Address Matt McCarthy Owner Owner's Name information is required wired for every Marstons Mills MA 02648 9-2-16 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 ❑ 9. 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? i ® ❑ 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) 1310 CMR 15.302(5)1 D. System Information i I 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 qt t5ins.doc-rev.6116 Title 6 Official Irspection Form:Subsurface Sewage Disposal System-Pape 6 of 17 =7i 77 Sep 04 2016 13:16 Jim The Inspector Man 5085349919 page 24 t r C\ Commonwealth of Massachusetts 4t� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments •�'� 10 Cherrywood Lane Property Address Matt McCarthy Owner Owners Name info required atlon is every Marstons Mills r aired for eve MA 02648 9-2-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit f Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No FN Water meter readings, if available last 2 ears usage Well Water ( Y g (9Pd))� Detail: Sump pump? ❑ Yes ® No 3 Last date of occupancy: Present Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) 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: t5ins.doc•rev.6r16 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Sep 04 2016 13:16 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Cherrywood Lane Property Address Matt McCarthy Owner Owner's Name information is Nlarstons Mills required for every MA 02648 9-2-16 page. cit crown 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: 12-2-11 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 "t 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): 15ins.doc•rev.6/16 Ti1Ie 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 8 of 17 Sep 04 2016 13:17 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts u Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherrywood Lane Property Address q Matt McCarthy Owner Owners Name information is x required for every Marstons Mills MA 02648 9-2-16 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: NA New D Box 9-2016. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 46" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - a r Distance from, private water supply well or suction line: feet M Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site plan): t Depth below grade: 3 feet Material of construction: FpjFl l ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth_ t5ins.doc•ray.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Sep 04 2016 13:17 Jim The Inspector Man 5085349919 page 27 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Cherrywood Lane _ I Property Address t Matt McCarthy Owner Owners Name information is required for every Marstons Mills MA 02648 page. City[Fown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cost.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1" 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 at 3' below grade w/outlet cover at 1'. 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 F g polyethylene El (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.doc•rev.G116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 e Sep 04 2016 13:17 Jim The Inspector Man 5085349919 page 28 it t Commonwealth of Massachusetts Title 5 Official Inspection Fora' a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherrywood Lane i Property Address f Matt McCarthy Owner Owner's Name information is Marstons Mills required for every MA 02648 9-2-16 e page. City/7own 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.): E 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: t Capacity: gallons Design Flow: gallons per day r 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.doc-rev,6116 Title 5 Official Inspect on Form:Subsurface Sewage Disposal System Page 11 of 17 Sep 04 2016 13:17 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts a . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 10 Cherrywood Lane : Property Address Matt McCarthy Owner wn Oers Name information is required for every Marstons Mills MA 02648 9-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ft 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"-39" Below grade w/one line out D Box is new 9-2016 w/cover at 8" of °t 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Sep 04 2016 13:17 Jim The Inspector Man 5085349919 page 30 :t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments n� 10 Cherryw ood La ne Property Address P Y Matt McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-2-16 page. CityrTown State Zip Code Date of Inspection + D. System Information (cont.) Type. ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number, ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, e:c.): Leaching is a 1000 Gal. Precast pit. Pit and cover at 29" below grade. 30"water in pit. W/stain line at 6"above water line. No sign of over loading or solid carry over. No high stain line f. 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.6116 Title 5Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 Sep 04 2016 13:17 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherrywood Lane Property Address I� Matt McCarthy Owner Owner's Name Information is Marstons Mills required for every MA 02648 9-2-16 page. Cityrrown State Zip Code Date of Inspection D. System Cnformation (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: :l Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r� { 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Sep 04 2016 13:17 Jim The Inspector Man 5085349919 page 32 t Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `{ 10 Cherrywood Lane Property Address Matt McCarthy Owner Owner's Name information is Marstons Mills MA 02648 9-2-15 required for every page. Cityrrown 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 k _� �! RJR B ,4 el n J A.3 R-3 ^ 3 t � 3 o� t :r eRRF R t5ins.cloc•rev.Ull6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Sep 04 2016 13:18 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Cherrywood Lane Property Address Matt McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na 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: You must describe how you established the high ground water elevation: Ck. area +Auger T.H. 14' no G.W.. Bottom of pit at 9' below grade. Bottom of pit at 5' above T.H. Depth. �r I i i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i i Sep ,04 2016 13:18 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 10 Cherrywood Lane Property Address Matt McCarthy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-2-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked g ® 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 if t5ins.doc•rev.606 Title 5 Official Inspection Form:Subsurfa:e Sewage Disposal System•Page 17 of 17 No. l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,./ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatlon for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. G 1.1e:,RR!/i�p�� c." Owner's Name,Address,and Tel.No. 4 M4TT*GW 4—U (RJca�b CAPOLYAJ /k 4 Ny Assessor's Map/Parcel © l 2I ®b 1 Installer's Name,Address,and Tel.No.SC _4'7 7`7 Designer's Name,Address,and Tel.No. C�D�c� 6NJTRU � �<164sg Ci[ e- Type of Building: + Dwelling No.of Bedrooms f Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) AA gpd Design flow provided A)A 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) a f`'-A0 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. e C Date —3 Application Approved by - Date Application Disapproved b Date for the following reasons Permit No. ZP« 31 Z Date Issued 061 31/70/(o ! a No.2W 1 ,:. . »,_ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓� PUBLIC HEALTH DIVISION h TOWN OF BARNSTABLE, MASSACHUSETTS Yes appIiration for Misposal -6pstem Construction 3permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 10 C 14f_-RR-YW6d6 (,N Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q ( Q! o a Mtil 1 D Wchob W M M Installer's Name,Address,and Tel.No.& _LJ-77_$%-I-1 Designer's Name,Address,and Tel.No. C-AP&W, t)s 6WTSKP4 4s&-s 4.L4,, Type of Building: Dwelling No.of Bedrooms N� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Affl gpd Design flow provided A)A gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i E. Nature of Repairs or Alterations(Answer when applicable) (-('-eZC- 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. e 2 //Sr ne , Date Qt9 Application Approved by G/ Date p ,71 Z b Application Disapproved b� Date for the following reasons Permit No.0"16 31 Z Date Issued 3 za, (o ----------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by C14,p(.;:W(TJE (Lc_ at I o _o Lk,pab LA-PE Mn_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.nOIO 3(2- dated Installerk� p�Q4 L� t Q�CPII //�� Designer #bedroomsa)Pf--- Approved design flow and The issuance of this permit shall not be construed as a guarantee that the system willl.•function.as designed,. Date I J � Inspector -------------------------------- ----------------------- ------------------------------------------------------------------------------ ; No. So XZ. Fee n THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3permit Permission is hereby granted to Construct Repair Upgrade ) Abando n ( ) System located at QS GEC.. 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:Co stru tion must be completed within three years of the date of this perm' . Date Approved by F� 3 RECEIVED COMMONWEALTH OF MASSACHUSETTS OCT U 12003 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI STOWN OF BARNSTABLE HEALTH DEPT. Z W DEPARTMENT OF ENVIRONMENTAL PROTECT p�M SVev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 O Owner's Name: RUDOLPH DIPERNA Co Owner's Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Date of Inspection: 8/26/03 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally s es _ Needs Furthei aluation by the Local Approving Authority Fails Inspector's Signature: Date: 8/26/03 The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio . If the.system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMIPNG EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 incnertinn Fnrm Fil si?nnn Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMIPNG EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: n/a .n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Z I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h 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 3 YRS, PER OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ 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 If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out" X _ Were all system components, excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):aria Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL 1 Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: 3 YRS.PER OWNER Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons--How was quantity pumped determined? n/a 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) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 11 YRS PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO A Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) - Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6"H 5' 7" W 4' 1011" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 WAS VIDEO INSPECTED AND IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPER'NA Date of Inspection: 8/26/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAD FIN IT AT THE TIME OF THE INSPECTION AND HAS NOT HAD MORE THEN Y INDICATED BY STAIN LINES. THE BOTTOM IS AT 8' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a IL Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. Le I6ray AA q t5 r� �0 36 in r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 CHERRYWOOD LANE MARSTONS MILLS 02648 Owner: RUDOLPH DIPERNA Date of Inspection: 8/26/03 SITE EXAM „. _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER- 12+FEET 11 ' TOWN OF BARNSTABLE LOc:ATION /0 QXSEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 000 LEACHING FACILITY: (type) (size) 1060 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)' Feet Furnished by 1 AA Ab H �g AC I� AO Q �79 Bc 31 36 . Io TOWN O BARNSTABLE . 6 UWYr f_ . LOCATION �} 6Ul�'`r� `_ SEWAGE Vii`:I.AGEet�T��r (�1 /In �l S ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY `000 co ri LEACHING FACILITY:(type) 10 1 (size) s NO. OF BEDROOMS '3 PRIVATE WELL OR UBLIC WATER p � 4 BUILDER OR OWNER / DATE PERMIT ISSUED: LQ DATE COMPLIANCE ISSUED: v VARIANCE GRANTED: Yes No �` N No........................ ff� Fim....,�,19.4�........... ?�f THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH R 42 \ ........ .... ...............OF...... pliration for Dispniia1 Workii Cfnnutrnrtiun Famit STVW s�0 n is hereby made for a Peet to Construct ( 41—or Repair ( ) an Individual Sewage Disposal —.a ... car..... _.. 4 ..I...... ' 2. - .........1_0T_Z. r� cation-Ad s \ 1... _.. C' >....... .... '-Q.Z•€�4.�.......`..r'i Y� Owner Address a ..... ,................................ ••-•--............•................ Installer Address /�,/� -7 44: qq -- �U. Type of Building - `� Size Lot......:............[._.1....Sq. feet �-, Dwelling No. of Bedrooms................ .......�—__J........._..__..Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .............. No. of ersons....•_______.........._.____ Showers a YP g ---•••--•----• P ( ) — Cafeteria ( ) dOther fixtures ....................................................................................................... W Design Flow................ . gallons per person per dad. Total daily flow---- gallons. g 5.5.....-----•-- _ .. WSeptic Tank—Liquid capacity.J5�gallons Length...�.�4,.. Width.!.(- xa hiameter________________ Depth...�-' x Disposal Trench—No. .................... Width_.'(.........--.•_.. Total Length___......_1......... Total leaching area___••_•_------------sq. ft. Seepage Pit No.......1............ Diameter.._.]®.=�3 ._. Depth below inlet...A............ Total leaching area..-MA 64v Z Other Distribution box ( 411*" Dosi tan tkW�... Percolation Test Result Performed by.. �_, ��l) L --: -.MA.... Date....._- - i-�_ ----------------- Test a Pit No. 1................mmutes per inch Depth of Test Pit..._/ ......... Depth to ground water I'TOA --_____. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------- O Description of Soil------ ..,"'_ ...........r _Z. =. °�..�...' - - '����U - U �----••----------------•------------------......------.........-------•---•....... W U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------................................. .................r....................................................................................•................................................................................................ Agreement: -f' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T Ili L I, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuedby the board of health. q, Signed....... --_-------_--- ......./n at;/z/.-- .e /Dat . Application Approved BY-••....----- � U d� -----------(v' Date Application Disapproved for the following reasons:........................................................-........................................................ -•-•-•-•--•---------------------------•-•-.....-•------•-............-------------------•--•----...------I-••---••----••---------•------•----•------••--•------------...-------------•------•-•------•--- Date Permit No........g`� Date r P ....`..... F>cs. /0.0............ ySW O �t4j1' THE COMMONWEALTH OF MASSACHUSETTS ROBERT �r BOARD OF HEALTH E. .:....................oF..... S Appliration for Disposal Works Tonstrnr#iun "rrnti# NAt,.. plication is hereby made for a Permit to Construct ( 'fir Repair ( ) an Individual Sewage Disposal ystem at C. °►- r, ,, cation-Add /' _ • 1 �€ - „ '..'.v/f -r,-?..:.............. 7 � r �� - - _`__ -k3aC---- :1 j� ax Owner Address � nstaller Address ff�� UType of Building Size Lot..._� `1: .� ....Sq. feet a Dwelling—No. of Bedrooms............4..........................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.......... ._.............._._fg4ons.�� WSeptic Tank—Liquid capacity 151�4gallons Length__ !_`��__. Width� .-".4;. Diameter................ Depth_.. _.`_. .. x Disposal Trench—No. ................... Width......._.......... Total Length..........1......... Total leaching area_--____-.._.. ....... ft. i 1� Seepage Pit No.................... Diameter....: -_��+..... Depth below inlet.................... Total leaching area......... Z Other Distribution box ( Dom `. tank,.( ) { aPercolation Test Results Performed by ? _. f d ) ` .._. � - __. Date_._.._. . , _ . _ _____.... Test Pit No. 1...L.....__.minutes per inch Depth of Test Pit_.' it... : ........... Depth to ground water.1?'610 Q......._. (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ — ---- ------•---- -------: -t----------- O Description of Soil.... '� •-- .. `°�,'?� ' ? .a. , ..r - .'.. '�.�4 Al x Ui- -....................................T......................................................-............................................................................ W M. ------ -------- ------•-------•--------------•--•-----------------•---•-•----------------•----••----------------------------------------....--------•---•----•--••-----•-----•----•••-•--•----•-•---•-- 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 TITS; 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 pf health. Signed--- ......................... ....... Dat Application Approved By............. - --- .. ----------- Date Application Disapproved for the f101_0�winga reasons---------------------------------------------------------------------------------------------------------------- �P ...................................................`....................................................................................................................._............................... q Date PermitNo.......•/l:-Z- 74......................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ,.QF HEALTH .�i ............OF...........x..,,1 ..=�.C.+``� .............. .... Tn#ifiratr of TAntltliFanrr �. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ��or Repaired ( ) by �i E - Installer at...........�.� --••--- �'�he ��:W---------- ---- r -- ---- -------- has been installed in accoanons of 1.1; 5 of The tate a.nitary Code as described in the application for Disposal Works Construction Permit No.-__-_---_-.fi dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r V DATE.................... ......_ .. .. .................... Inspector........... ..................................................... THE COMMONWEALTH OF MASSACHUSETTS ,...� BOARD F HEALTH 1.�1 .............0F.......... r .................. No...... 1'.t _u FEE..../ ....... �i��rn��a1 nrk� �nn��r uan anti# Permission is hereby granted.------ ....... ----•--------------------------•--•-----...........----•--•••........... to Construct ( or Repair ( ) an Individual Sewage Disposal S st at No..........L,..�&.7....4.• . ._ ..__... Street as shown on the application for Disposal Works Construction Permit No----�_S;�6Aated.......................................... ..............................---•------ -----------I---------- •---•--•----•------ DATE - ��•- J�........................•......... a'd atth FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ! � IL 4� r i _ yy 'p Igwpm-'F^ ' rM �IIA'M e'I+i-✓<..Ys..s+a.•, w a,-tTW+11M.<+<W 1 !.« 4 ,R.' a a c� - 1 7 .. .�. '� ,_ ,.:-: a � _a',,..-.. •.. � � _ d, ., .; .. id' - �.v i I .7 t V i .. � -. e,• f. r; 0 10' - 6" s X at.a #Tra :errrvsxes:tzJ e, TOPSOIL ' _ ._ -- SUBSOIL _,,.-•- `� < l T$ � l ` g ��y 1/ C .i N�.�. .I.!'i'E5. 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F �r*,E 'LEAC!�+�%h f-l' FOP I < k H l �' �; •.� t, _ - .._. _ .tl _. .~< } ^ 1. t �.� �,.� � , A I�+$,7*4CF r o - •Y F .� Lrl•RY/r, ui-1. *TH �,L►'Y`-- } TYPICAL. DISTfR<B BOX � k7''�, "t ' a.< < !rt ' ' - 1 it 1. - -- --- -- + ."•„r s'. .r.. . "I F.C. Ml{R.J a -51RA 'F.L HAVING A F,o11Jt-A l ��,.fN ROS 1 f.. n..:�.. OF '' RQINUTE�I > INI;H ZIP LE S 15' v1arE DISTRIBUTION SOY AND 1504 i 'F TOWN OF BARN ThBLE f3 R ! : NO WATER ENCOUNTERED l p '� .�g- 9a, BE A�MlWTIFII~:'J WHEN �'dE SYfiTEM SL NEAR' COW..ETt+�IN GAL REINFORCED SEPTIC TANK 8Y I iV ffT �"YP$ AL. C SEPTIC TAt' >acMEcA�T 09 u TYPICAL LEACHING PIT aN>a P�rvt TO FII.l,1I`lC, jai a _,__.. . .. _M. . - - 5w:SE I Al I. SYcT€l�t C a a ACCORDANCE `WITH 'rAri_.E. rEt :C1,AFt +t RATE > 2 min/it ch Nqr r :SY�tGE /vor rQ S!C F. 3MA I �3 ,N.STAI.EED ItV € < �fRNaT,,(() $ 8Y ED BARRY N074' TANKS kEiNFORCED THFi't�t+HOUT WITH Ot THE �TAtE SANITARY !M ANC) A' LOCAL bARNSTABLE 3C►ARf) OF HEIALTH ELECTRIC WELDED WIRE WITH 44--i/2' RULES WHICH MAY AM" I.'W5`lhEh G ARO ENGINEERING INC. EMBEI D STEEL RODS IN TOP Bi 80T - 8 CONTRACTOR IS TO NOTIFY. ENOMEI�, 'RICIR -�Cr '. 4 t :.1 :. JUNE II, 1991 TCMN CONCRETE tS 4,0W PS I TEST iIVS ALL.4T1(}Al OF p?IC SY T iR. £> ANY .Q1 N - A AWI;ES BETWEEN ;'EST I; ? i�'SUf T5 AND V*1.� - C;Qf�p►TiC1NS. 9. Af�GE9 I�fA•NNCK T "i f'r'C 'TA 'S AN6, A00W PITS TO BE SUILT UP TO �� #f�iGNE"5 . IB�L� FBI P19. 79 21.50 •05,35,~ L2 y / TOP OF 10. NCR S-TM AR" I& NOT TO � USEQ POR AR I liOPOW.S< 6� �. 6g FOUNDA' IONS 5 r;�, x { { 1*.`0. ELEV FINISH GRAD: FINISH ADE FlNtSH GRADE OVER LEAS_.-7 ! 44479±sf _ s6 FiNISH GRADE �OVE`R TANK OVER "DI 81 c fxREA ELEV -57+0± � �"ELEv.T 59t00 V = +5 EL EV = 57+70 % 5 T 6 rrr: E� E 58 OEX! T is 64 , ''t' �,RisE o ,. .._ 9�. ,'}RISER ' '.1j INV= - _ 53#75 Cry NV= 53+00 INV - 52.83 °w_ _ . c ;s► S iNV - 53-50 i am. ;,;' INV= 53.23__ "r- •O cJ'/ 30 ! r: ' w�C * p Jv: . . . i•a "t ..y.7'T'CJ1�(t._ ' v LEACHING LEACHING 6 I �F 7r I��` t . . • .. •• c•t` .. PIT PIT ( �L.;w+- f r.< . <.••. BOX b t ' y _--_^ _. .1 t . . : •• <.r I�-+ wsi•o [.r "ANY . • � T 52-50 61 i � :.' ASEPTIC TYPI CAL SEWAGE SYSTEM PROR L E D ' T NC? r0 .5.4L E RR=\ z ti °p rn 11). N P PROPOSED 45 , N L EG E NO _ �+ o DWELLING �` m _D 1 jw�. F.FI=6 50 MAP SECT 0N P � LOT VT. _A � .� _ J+l m � I �� - -- - 41 . __1•-____.- 12 COSC1•--_�.-___----6 f PROPOSED CONTOUR i I I IF.XIST SPGT ELE�JATI()N 8 X0 nr' l � I PROOSE SPT. EC_EVATI( N r< ZONIhG O s.T.- I�� �LO A �t, �� 09 PERCOLATION TEST m m RF t47.34 0WRVATION PIT CIVIL ' PROPOSED 4LOCATION OF DWELLING G T KERRYW DE SIGN CRITERIA D CROSSING SEWAGE D1POS4e. SYSTEM SeZ �" NUMBER 01 E. BEDROOMS 40.7 y� , RAYMOND LOT 6 KERRYWOOD CROSSING E"R P N PER BE D"M No.; 7s Z r . GALLONS PFR PEA! PER DAY , 'SS � c,sY�A �� ��; COTUIT (BARNSTABLE) MA. - .Ir AC.�ttAIC ' I�Q'v►► 'o AM gpd A w gP _ _ - .#;:.EACt•f i l�tG °RCjN�t} 733 2 d WSPOSAL NO : -, APPLICANT 'EN G G . NEI , • . A THEO CONSTRUCTION CO. k SEWER DESIGN o�� �c� 24 GREAT BOND DRIVE 39OTRWEREAINE IN(.. ' ROBEAz 2 x x 5 x 6 I.67 - 314<8 gpd S. YARMOUTH, MA. 02664 E. FALMOUTH, MA, 02536 r Y 40 40 80 tI�E z RAYMOND . . -...._. . .�� .. ....,.;...w...r. p No.21583 �;1 r x 5 - 0.66 51.8 gpd q� Quo '•!� JUNE +sT AS SHOWN Ii, 1991 I, of SCALE IN FEET r€`TAL 1 ~366.6 gpd x 2 = 733.2 gpd � J r A - .703 �.a P 7771 $ RER _ REIR . .,--....nv+....v-+. ..,r•r....n.r..wq......<..w....!-,., .sw<-,..-F.•.._.-..a-x w.r+w...+r _- '--+.+.A+:...ww•w,a,w.+...r,,.p-.._. ..-..,uR++w.^+'.+r..+«.._w.,.a._,..n+....r...+.wvwr...w .-'Mrrs......«.+.e....Y.+s._...-....ww.+MCI.Yk.....-.<wv..rAa :w••.+«n.,tM'. ..Pt+"7i+q1•y`^'!+YPi!<"'.w+A'L<r.iw<+ +i.w,e,Unw-sM.tP,..�rFwwr.iVT . .Nrn.aMtAM ,r+• 45 '^ wM<a!MW/ ( px`• e +, ^F.Y4,.ww'<Mwnhwwy...w..t+wra...-..<+w-..,..- .+.-..................-.. ...w.'.._..._.•.,.r,..... .. .- - y