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Home My WebLink About0048 CHINE WAY - Health 48 Chine Way —� - - Marstons Mills A= 098-069 i r' 06 LOCATION J v�� G /�� SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S MAE & ADD ESS B UI'LDE R,/� 0 OWN R 1� Pa 472 DATE P RMIT ISSUED DAT E COMPLIANCE ISSUED 7A 14 1 C F S No......at...... Fiziz ..�r.......�9....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, HEALTH .....--.�l�..........0F........... :.......... - --_--------_------- Appliration for UWposal Works Tonstrnrtiun Pumil Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Dispo 1 System aC_ f�` b V v 1,54el 1 0�� — �� - • -- L d o Lot No. Owner Address a ...................................... ............. .--------------...__.._...........---- --------------------------------5°6---- -------- ------- -----_-------_------ Installer Address Q Type of Build' ��-Size Lot_ ........ .....•Sq. feet U Dwelling No. of Bedrooms_____________�.......................Expansion Attic (v`�� Garbage Grinder (� Other—Type of Building No. of persons...........:................ Showers — Cafeteria a' 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..................... .W'idth`.�....•�__._....___._. Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter�.r�CT___... Depth below inlet. _.... ____------- Total leach' g area____-'Z_a_ _._sq. ft. Z Other Distribution box ( ) Dosing �c = Percolation Test Results Performed by... .... .... _--------------------------- Date.......__..._____-_--_______________-. aTest Pit No. I................minutes per inch Dep h of Test pit.................... Depth to ground water._-________-__.._•.-._-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ a ` J ---------------------- . i-----e-----•. ------------ O Description of Soil............49- v' ...Y_ - - r� 2 , U ---------------------------------------------------------------------•---•--------------------------------...---•---------•------------•------------------------------------------------_-- W -•-•------------------------•.._..•-----•----------------------•••---•-----•-•-•••--•--••••----••--------•----•---•--•--••••......----•----------------•----------------------------------------------- UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------_•-.__-_____._.._____-:_.________-__.__--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agre of to place the system in operation until a Certificate of Compliance has been issugd board ealth /y �Signd.-- --.... ..-----•--•--------••- -- -- ----------------------------------- -------Application Approved BY - J � L� =��-Date 7 ._...__. Application Disapproved for the following reasons:-----------•-----------------------------------•--------------------------------------------------------------- ------------------------------------------------------------- ------------•--•---••-•----•--. Date PermitNo......................................................... Issued----------------- --....-----U-------............. Date '- --------------- -I------------------------- ---- No.---(.. ........... FEEr ................. THE COMMONWEALTH OF MASSACHUSETTS �1 BOARD OF HEALTH r �4> Apptiratiun for Disposal Works Toustrnrtimn Wrmft Application is hereby made for a Permit to Construct (&11)/o�rRepair ( ) an,Individual Sewage Disposal System a1-7 C" l ( ) /!:` 'SI rl�C�G✓jj _ -. � Location 'Address / / r or Lot No. Owner Address •---•--------------------------------==--jG......_.........-----•............................... .................................. - --------.............................................. Installer Address Q Type of Build. g` Size Lot.�...�._✓�:____Sq. feet Dwellin No. of Bedrooms............. ........................Expansion Attic Garbage Grinder. (I—)- Other—Type of Building No. of persons............................ Showers — Cafeteria Pa Other fixtures ------------•---------------------------------•-•• • W Design Flow------$-r._..........................gallons per person per day. Total daily flow...,y..jd---------------------------gallons. WSeptic Tank—Liquid capacltyf__._______gallons Length................ Width---------------- Diameter---------------- Depth---------.--._: x Disposal Treo'ch—No..................... Width-------------------- Total Length.................... Total leaching area...........f........sq. ft. Seepage Pit No........w........... Diameter?y?__�e__.. Depth below inlet.................... Total leaching are1�.0__C.-------sq. ft. Other Distribution llox,( ) F Dosing tank �.ai. OC . 3w 4-0� 0-4 a Percolation Test Results Performed by__ .........._1!n.................................... Die__.....'.4�_'-_-78__________---- Test Pit No. 1................minutes per inch DA�pthf Test Pit.................... Depth to ground water..-___-_---_-_--__---.-. f� Test Pit No. 2................minutes per inch Depth of Test Pit................._--- Depth to ground water........................ x y/ � -•-- - - . [Description of Soil_. / t_q AV -J - U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. �.� _71, Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in.accordance with the provisions of Article XI of the State Sanitary Code-The undersigned further agrees'not to place the system in operation until a Certificate of Compliance.has been issued by t e board'of•health: ` • //� Signed = Date Application Approved BY----•- / .. --- li !� _a-------------------- -7ram--'------------ f V Date Application Disapproved for the following reasons:-----------_-•-------•--------------------------------------------------------------------•-•-••••••--••-..... ----•----•------------------------------------------------------•-------......---------------------------•-••--•-------•------•--------•---••-----••-•-----••-----••-----•-•-------••-••••--•••-•------- Date PermitNo......................................................... Issued............./=!-••---- ......-------------- Date k k THE COMMONWEALTH OF MASSACHUSETTS j 'BOARD OF HEALTH .r- 10 !... ..........O F.... .. . ........ ....0............................. ..• (Irrtifirate of Tnnwhaurr TH S is TO E T FY, hat t ndivid SewageDisposal System constructed) or Repaired ( ) by ----- ------��./ .... Installer ab,.n. - --------- ----has been i nstalled in accordance with the provisionsf6f i XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. _. dated___ _.fi�"_ _�_______________ �' f `--. THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIS CTORY. � DATE................................................................................ Inspector----. ........ ------..................................... 4 ,... THE%',COMM NWEALTH OF MASSACHUSETTS BOAR OF H k TH �^- .... ✓�. ............OF. � Nd'' (............. FEE------.................. Bigpoin l IV It li#rurtinn "unfit Permission is hereby ranted---,, ._. _ +i to Constr,. K11. ) or Rep Z an In iy ual Sewage System at No.. tl .. ;:: Street as shown on the application for Disposal Works`Construction mit o Dated... ` 7� r� �C�f9Ef Lr.�� L�11E1 DATE. Board of ealth FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - Dt�-- r�t--L vnT� K Qu W I m-I G.A 5Aic.6 Gilt w DQIL vA.%L--( 1=L,c,,A/ n 110 Sep tG TANK • 4q�j '2AU �jL ' dGGjD �iPT7 I USE //••A. � 1 ( � �80,4E { %>1SP0'SAL ptT V;6 E1A/ cO 3tDAt.L �� = IVc/ 7� ' r! {_ -Z, r Q Lea '410 G-Pt), BoTTOAA AtZEA• 8 5F ` 78 SF �c ► -o :fit 8 G� `Z40 I `p PEecoLoT low`" eA-(T-. C i w- Z fwu :o¢C" ,.s_ 40. t lh tXi? p,r r e > � 6FR �!�( i 1N OF hf� G-$oX i RICNARD A ANA. BAXMR 40 ti' � C� ,�0�` IST��i v t + ..j�'.1 i s �t' i i .i• i � r �,�.*� 0 N'l- ToPUD• bo' �� k N� y' itV�'•� �' � t% l.vay i Np 4 IWV. coA.L. 1 I a 4t ! saX I r':;4G�. Xs6rP�IG r t { L' two TAtJK � i r CQ00 0151 b + , GAL. � :4 MEn Ptr - � i . .. . �. STcuc 2 -t ! PL-A.#,4 i I ��ZO F I L.tc LXk-,A r10 W . 05TEQV(UX-- 12 WO 7Q4L f-- / 5GA / l Igo 1l�A�n. d 4 -18 1 CrA6rM FY T"AT Ttr'Ff- . FOU t-�trs tJ-�:4 lO h1 ShawU ' i i I Ql—A.1-1 IZE�EJZ�JG� R $.J GO/APY S W�- t TH. -r"F �IDELt tat ' t AWD SETBACK fZEQuttZLMCat•iT; of .T1.1E 'mv-/" oF' 73A2 45TAI?)t.E _{ 0 57 - �I tLS ' �E�i► 4/4/� DATE - 1Z S+C.-tSTW W-M'> LAWn �QVE`QOQX. T441S PLdt•1 14 IJOT BASED .oU AV •ltJyT?uMEuT- + OSTaLvI. . MA.S+S. SuCvm/ TWQ O9F"S4T; .�ib4ouLD �IoT.. $& uSE,�p APPUC.A Wr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms 05001 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service Company Name 17 Playground Lane Company Address Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S14454 Telephone Number License Number B. Certification h —•4 1 certify that I have personally inspected the sewage disposal system at this address and th lithe C? 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 toSectionrl.6.340 of Title 5(310 CMR 15.000). The system: 0 Passes ❑ Conditionally Passes ❑ Fails -� 7`j ❑ Needs Further Evaluation by the Local Approving Authority C.) ((�&0131. 5/14/14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Yc.e age Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Chine Way Property Address GRALTON KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑x 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13 System Conditional) Passes: Y Y ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 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 pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s °y 48 Chine Way Property Address GRALTON KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 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 thus 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 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'/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ FX1 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 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.] ❑ ❑x The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑x The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Chine Way Property Address GRALTON KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 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 ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ M 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? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑x ❑ Was the site inspected for signs of break out? • ❑ Were all system components, excluding the SAS, located on site? ❑O ❑ 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: ❑ 0 Existing information. For example, a plan at the Board of Health. ❑ N Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes O No information in this report.) Laundry system inspected? ❑x Yes ❑ No Seasonal use? ❑ Yes Z No Water meter readings, if available last 2 ears usage d na g ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): p y(gpd) Gallons per da Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts rn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Robert Paolini Septic Service Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °r 48 Chine Way Property Address GRALTON KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14114 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑ cast iron ❑X 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 1' feet Material of construction: ❑X 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: 1500 gl Sludge depth: 4" t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from tcp of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" Distance from too of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of constriction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts 0.0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑x leaching pits number: 6'x6'with 2' stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure. Leaching was dry at time of inspection. 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-3/13 Titie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments «, r 48 Chine Way _ Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately —�T �J J L<1) 3 t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e' 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: O Check Slope ❑x Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 22' 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) 0 Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Chine Way Property Address GRALTON, KATHLEEN Owner Owner's Name information is required for every Marstons Mills MA 02648 5114/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D, or E checked 0 Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑x System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 X� � Ge- i w -9� «�e I CNI I o OK r II i ' I r ; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Chine Way Property Address Conkling Owner's Name I/� tastable VY `0�00) 'Y U MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Citylrown State Zip Code 508.272.6433 Telephone 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-16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ' 9/19/11 Inspe s ignature Dates ' The system inspector shall submit a copy of this inspection report to the Approving Authority(B�, rd of Health or DEP)within 30 days of completing this inspection. If the system is a shared system-,gr has a design flow of 10,000 gpd or greater, the inspector and the system owner shall su& it 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. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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 ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: 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 C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 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. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Chine Way Property Address Conkling Owners Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 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: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Vacant 2 monthsper realtor Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Regular pumping per realtor Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1978 per BOH file Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: it 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: 1000g Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle >21, Distance from bottom of scum to bottom of outlet tee or baffle >211 How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Chine Way Property Address ,Conkling Owner's Name Barnstable MA 02655 9/19/11 Citylrown 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet � Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level w/the bottom of the 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 1'6" below grade Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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, etc.): Leach Pit 20" below grade with 2'of effluent in pit at this time. Stain line 18"below inlet invert. No signs of backup Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12' 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: 1978 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: see above Commonwealth of Massachusetts Tiflq 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Mt 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. t � o A 3� � 3� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b , 48 Chine Way Property Address Conkling Owner's Name Barnstable MA 02655 9/19/11 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): n/a C • N W V 'yy 4 .w.,.m.,em... u.essm.n....e.,�r^r.e•�..'•.r........ ......e.�,..e�r.r•..-�+.m......«. ,�«.wn�«gggS� If C), E F � - M,,`,OZ .ice-:j ♦.- ' e .. r t •. 1 , r } i .g �l �1 f h k r y .` ifP0, an #n Barn s- Uble .. MA Address 48 CHINE WAY _ PreparedJ For ABI'GAIL O'BRlEf� Assessor's Map:, 098 Lot: 069 Baxter Nye Engrneerrng & Surveying Community Panel Number 250001 '0544 J, .Effe'ctive ;Date 07/16/14 Registered Professional F.`I:R.M. Mop Zones: X (un-stioded) Engineers and Lurid Surveyors No Reference: Land: Court Plan 25575-a Sheet `1:, Lot 27 78 North Street;_ 3r.d F!Oor Cer'tiricate of Title.:. #203839 Hyannis, MA 02fi-01 Phone (508) 77-7502 fox - (508)-771rw.! . fawner. Abigai C. O'Brien,. Trustee: Abigail Trust U i d 2 13 7.1 Scale = 30 Date : 0$ 18-2016 Job Number.2014-051 ` N/F CAROLE M� GARVEY, TRUSTEE GARVEY NOIOINEE TRUST. CERTIFICATE 178470 PARCEL, 098-068 N $5'34 33 i. 171 00' L.ee^) c,►< PAPCL 008---a6>9 `\ na. NJF CRAlG E & MANGY.A. l c zs, WHITELEY7 F1CATE 178479 PARCEL 121-166 l �' l:. ' + M. O. y1� r oFf° �a 41 K%. � G 1. EpSEN{ENT ;.. . � 8514'33► � tc13 � I -. NOTES. 14 A TIRE SEARCH HAS NOT'BEEN PERFORMED FOR THIS SITE. THERE MAY BE RIGHTS BY OTHERS, EASEMENT, TAKINGS, MORTGAGES, RIGIff OF WAYS ETC.: NOT DEPICTED. IF DETERMINED TO BE NECESSARY, A TITLE SEARCH SHALL BE PERFOPMED BY OTHERS AND SUPPLIED TO BAXTER NYE ENGINEERING &,SURVEYING. 2. THE PROPERTY LINE INFORMATION<SHOWN IS BASED ON CURRENT AVAILABLE RECORD INFORMATION CONSISTING OC" PLANS AND DEEDS THE IXIS11AtG FEM ES SEiOWN HEREON �YfRE 080NED FROM AN ON THE GROUND :RELD.SURVEY.:PERFORMED :BY BAXTER NYE,ENGINEERING &;SURVEYING ON AUGUST 32, .20164. 3. ZONING INFORMATION: ZONING DISTRICT RF OVERLAY DISTRICTS. GP RPOD, ZONE lI, S:W.EZO:C. 4 StfE DOES NOT APPEAR TO BE WITHIN A F'RIOR1IY HABITAT AS MAPPED OM MASS G1S OLIVER PER NHESP 'PRIORITY HABffATS OF..RARE.SPECIES"'FOR SPECIES UNDER THE MASSACHUSE(fS ENDANGERED>..SPECIES'=;ACT REGULATIONS::(321 CMR 1;Q). 5 REFERENCE EASEMENT DOCUMENTS, 0233889 9, 233890-1, 233891-1 NOTICE DOCtlMM, 03$141-2, 224838-�2 I CERTIFY THAT TO THE $EST OF MY`:KNOWLEDGE' THE EXISTING STRUCTURES SHOWN HEREON IS LOCATED IN RELATION TO THE 'MONUMENTS SHOWN AND IS. NOT LOCATED WITHIN A SPECIAL FLOOD ;HAZARD AREA: A \ - THIS:: PLAN IS NOT TO BE RECORDED NOR IS IT TO BE. USED. TO ESTABLISH PROPERTY LINES: > . v r f4. REGISTERED1 PROFESSIONAL. LAND SURVEYOR N BAXTER NYE ENGINEERING & SURVEYING DATE