HomeMy WebLinkAbout0037 CHIPPINGSTONE ROAD - Health "�7 �hippir���+tone Road
Marstons INiills P
A = 027 035
r
Gob Socbello
bog- W6- q23
f
Cc,l/ LA c-7 ' �/
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out Ir
forms on they
computer,use 1. Inspector: � I
only the tab key
to move your Scott Campbell
cursor-do not Name of Inspector
use the return
key. Cardinal
Company Name
32 Ridgetop Rd.
Company Address
Cty/To Ma 02635
City/Town State Zip Code
508-420-1295 S1388
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. Tphp insaction
was performed based on my training and experience in the proper function andjrnaintenance--of orlte
sewage disposal systems. I am a DEP approved system inspector pursuant fiWSection4 5.34fff
Title 5(310 CMR 15.000).The system: °
® Passes ❑ Conditionally Passes ❑ Fa ifs
❑ Needs Further Evaluation by the Local Approving Authority
)
u► rn
6/15/2011
Inspector's ignature 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.
I
t5ins•11110 Title 5 Official Inspection Form:Subsurface SewagjDp.sal System•P ge I 1 a 17
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated.are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is Marstons Mills Ma 026486 6/15/2011
required for
every page. Cityrrown State Zip Code Date of Inspection
IB. Certification (cont.)
B) System Conditionally Passes (cunt.):
❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
-44 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health and Public Water Supplier, if an.
Y ( PP Y)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•11/10 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
37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chippingstone Rd.
.Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
t5ins•11/10 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
M ,•''r 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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)):
Detail:
2009= 36,000 gallons 2010=42,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy:
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: 2011
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
® Other(describe):
1000 gallon septic tank, 1000 gallon leach pit
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
r .
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chippingstone Rd. .
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1980 year built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 112"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:
Sludge depth:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
4'3"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? vbisual inspection, tape measure
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 does not need to be pumped at this time. Inlet tees in place at time of inspection. Liquid level at
proper working height. No evidence of leakage into or out of tank.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
P
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•11/10 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
GSM , 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
No box present
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner
Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Cityrrown 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, etc.):
Course sandy gravel. No signs of hydraulic failure or staining above 3' mark from bottom of pit. No
ponding or damp soil, normal vegetation.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 ChiPP 9 in stone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. Citylrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Chippingstone Rd.
(Property Address
iEllen Browne
Owner Owner's Name
information is
required for Marstons Mills Ma 026486 6/15/2011
every 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
3'3
O lr
15
40
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. �Citylrown State Zip Code Date of Inspection
D. System Information (cont.)v c
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 13+feet
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:
Excavation at time of inspection right side of leach pit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 37 Chippingstone Rd.
Property Address
Ellen Browne
Owner Owner's Name
information is required for Marstons Mills Ma 026486 6/15/2011
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �
37 Chipping Stone Road N
Property Address
Tao Nguyen '
r
Owner Owner's Name / ;:-
information is Marstons Mills ✓ Ma 02648 10-18-18 f'?
required for every
page. City/Town State Zip Code Date of Inspection :;•;
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 5`l*- /3qO
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
m Company Address
Sandwich Ma 02563
City/Town State Zip Code
rmcv (508)477-0653 S113747
Telephone Number. License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey �°"�"`°�"�"��" 10-18-18
:...ow:m•eren H.xw.o,o�,.�a.art�®®mmm.�am�.�i.pus
�u�:roe.iorowv:ae n.m
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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
c Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
` c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
< Commonwealth of Massachusetts
�n p Title 5 Official Inspection Form
5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ El clogged
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y2 day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ n Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Q . Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ [E] 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade.the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no" for each of the following for all inspections:
Yes No
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
E ❑ Has the system received normal flows in the previous two week period?
❑ O Have large volumes of water been introduced to the system recently or as part of
this inspection?
O ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ E] Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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:
❑ R Existing information. For example, a plan at the Board of Health.
❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
r' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
no design plans 2Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA
Description:
There were no septic design plans or permits available at the Board of Health.
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes 0 No
Does residence have a water treatment unit? ❑ Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes RI No
information in this ireport.)
Laundry system inspected? ❑ Yes E] No
Seasonal use? ❑ Yes [E No
Water meter readings, if available (last 2 years usage(gpd)): See below
Detail:
"`2016-44,000gallons 2017-40,000 gallons—
Sump pump? ❑ Yes ❑■ No
Last date of occupancy: currentDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Owner- last pumped 2 years ago
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2 612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation,and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
0 Other(describe):
Tank, SAS
Approximate age of all components, date installed (if known)and source of information:
House built in 1980
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2'6"
Depth below grade: feet
Material of construction:
❑cast iron ❑■ 40 PVC ❑other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
L
.. Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
V
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'6"
Depth below grade: feet
Material of construction:
❑■ concrete El 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
1000 gallons
Dimensions:
4"
Sludge depth:
32"
Distance from top of sludge to bottom of outlet tee or baffle
Orr
Scum thickness
NS
Distance from top of scum to top of outlet tee or baffle
NS
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
U� Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
St page. City/Town ate Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
M
Design Flow: gallons per day
t,insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
NA
Depth of liquid level above outlet invert
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
u=
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes No*
Alarms in working order: ❑ Yes [E No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
(1 ) 6'X6'
0 leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.R26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
!- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
u� Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leaching was in working order and was dry with a high stain line 2/3 up for the bottom.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
�m ,@ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,AP�
37 Chipping Stone Road
u� Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
Asbuilt Ground water
A1.13'5" 81-26' V Grade W
A2.16' 82.20'5" y
B3.291" C.40'
2'6"
I L
A ,
OO1611
2 6'x6'Plt 9
8 C
>11'1>2'6"
Ground water
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
I
Commonwealth of Massachusetts
�e Ti Sewage tle 5Official Inspection Form
Susurface p System Form -Not for Voluntary Assessments
37 Chipping Stone Road
L
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
0 Check Slope
❑■ Surface water
0 Check cellar
❑■ Shallow wells
Estimated depth to high ground water: No GW @ 11'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:
Topo Maps and perk logs for surrounding properties
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Information on abutting properties was used to determine groundwater in >11'. Bottom of
SAS is 8'6" below grade showing the bottom of SAS in >2'6"above ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
c N Commonwealth of Massachusetts '
Title 5 Official Inspection Form
(= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chipping Stone Road
v
Property Address
Tao Nguyen
Owner Owner's Name
information is Marstons Mills Ma 02648 10-18-18
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
F■ A. Inspector Information: Complete all fields in this section.
QQ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
❑■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Town of Barnstable
1.39.,, Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,MSPH
Wayne Miller,M.D.
Janu
ary 25, 2005
Ms. Deborah Schilling
3860 Falmouth Road
Marstons Mills, MA
RE: 37 Chippingstone Road, Marstons Mills A= 027-035
Dear Ms. Schilling,
You are granted permission on behalf of your client, Mary Denneny, to construct
and utilize an innovative/alternative (I/A) nitrogen reduction system at 37
Chippingstone Road, Marstons Mills, Massachusetts.
This permission is granted with the following conditions:
(1) A professional engineer shall be hired to design an I/A system for the
property in compliance with the State Environmental Code, Title 5. The
system shall be installed in strict accordance with the engineered plans.
(2) The applicant shall submit floor plans showing three bedrooms maximum
of the proposed home to the Public Health Division Office prior to
obtaining a disposal works construction permit.
(3) No more than three (3) bedrooms maximum are authorized at this
property. Dens, study rooms, offices, finished attics, sleeping lofts, and
similar-type rooms are considered "bedrooms" according to the MA
Department of Environmental Protection.
(4) The applicant shall record a properly worded deed restriction, signed by
the owner of the property, at the Barnstable County Registry of Deeds
restricting the property to three (3) bedrooms.maximum. A copy of the
recorded deed restriction shall be submitted to the Health Agent prior to
obtaining a disposal works construction permit. .
SchillingChippingstone
t . �
(5) A written monitoring plan for the I/A system shall be submitted to the
Public Health Division Office prior to obtaining a disposal works
construction permit. The wastewater effluent shall be tested quarterly for
the first two years of operation for various parameters as determined by
the Board of Health (usually for Nitrates, TKN, pH, CBOD, TSS, TN, and
alkalinity).
(6) The applicant shall submit a copy of the signed two-year Operation and
Maintenance Agreement (O&M) between the contractor and the
homeowner to the Board of Health. The engineer or O& M contractor
shall conduct inspections to the I/A system a minimum of twice yearly. .
The applicant testified that the home was purchase in 1980 as an unfinished
three bedroom Cape style home. The home currently consists of two bedrooms
on the first floor and a second "unfinished" floor. It is the opinion of the Board
that the addition of one bedroom along with the proper use of a new
innovative/alternative nitrogen reduction system at this site should not pollute the
groundwater in the area.
Sincer ly yours,
Wa ne M�Ir, M.D.
Chairman
SchillingChippingstone
Page 1 of 4
VMNSTATiU
Logged InAs: a rce I Detail Tuesday, August 21 2007
Parcel Lookup
Parcel Info
Parcel ID 027-035 Developer Lot LOT 46
__ .. ._........ _ _ . __ ... ............. . .......... _ ... _........--------._.,.-_ ...._..
Location 37 CHIPPINGSTONE ROAD Pri Frontage .162
........................__...__.. ......... ........ Sec
Sec Road 'SPUR LANE Frontage 162
village ;MARSTONS MILLS Fire District C-O-MM
Sewer Acct. Road Index 0301
4
Interactive ,
Maple a
Owner Info
_... .... ._...._ __._. ... .. _ .,_. _.._. .,... . .. .._ _._ . m .,_ ....
owner.5ORBELL0, ROBERT T & MOLLY C co-owner
Streets 37 CHIPPINGSTONE RD Street2
city!MARSTONS MILLS State MA Zip .02648 Country''
Land Info
Acres 10.59 use Single Fam MDL-01 zoning RF Nghbd 0105
_......... __.. _ _ .. _.. __ _. ....__......._ _._.... __._. ..._..
Topography Level Road Paved
_.... _. ........ _........... ..........
Utilities;Gas,Septic Location
file://C:\DOCUME-1\miorandd\LOCALS-1\Temp\2F7JV8HW.htm 8/21/2007
Page 2 of 4
Construction Info
Building of
Year f.. Roof .._.... Ext
Built A980 struct Gable/Hip Wall ,Wood Shingle
Effect Roof AC
1620 j As h/F GIs/Cm None
Area 7 Cover p p Type s
Int _ _. ._. _ _... Bed
Style jCape Cod Drywall 4 Bedrooms
Wall Rooms EtA�
'r4
Model Residential Int f Bath 1 Full h'
Floor 1 Rooms '
Grade,Average Minus Heat Hot Water Total
Type Rooms
._..�.__.._.__ ._._. Heat .... . ............ __...,,. _ Found-
Stories Fuel Gas anon Typical
Permit History
Issue Date __. Purpose Permit# Amount Insp Date Comments
6/14/2005 Addition 84795 $15,000 12/14/2005 12:00:00 AM
3/1/1980 B22036 $0 1/15/1981 12:00:00 AM MM 1 STOR
Visit History
Date Who Purpose
12/14/2005 12:00:00 AM Paul Talbul Meas/Est
10/13/2005 12:00:00 AM Jason Streebel Drive by inspection only
4/28/2005 12:00:00 AM Paul Talbot Meas/Est
2/2/1999 12:00:00 AM Donna Dacey Meas/Listed
Sales History .........
Line Sale Date Owner Book/Page Sale Price
1 5/31/2005 SORBELLO, ROBERT T& MOLLY C C176851 $298,500
2 3/7/2005 TESSIER, EDMOND E C176057 $258,000
file://C:\DOCUME-1\miorandd\LOCALSI\Temp\2F7JV8HW.htm 8/21/2007
Page 3 of 4
113 I I DENNENY, MARY E I C80634 I $011
Assessment History...... _. _..
_...._ .... __... ...
Save# Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2007 $138,700 $0 $0 $157,700 $296,400
2 2006 $101,800 $0 $0 $166,100 $267,900
3 2005 $97,500 $0 $0 $128,300 $225,800
4 2004 $79,100 $0 $0 $90,600 $169,700
5 2003 $71,000 $0 $0 $43,700 $114,700
6 2002 $71,000 $0 $0 $43,700 $114,700
7 2001 $71,000 $0 $0 $43,700 $114,700
8 2000 $52,600 $0 $0 $23,900 $76,500
9 1999 $59,500 $0 $0 $23,900 $83,400
10 1998 $59,500 $0 $0 $23,900 $83,400
11 1997 $56,900 $0 $0 $23,900 $80,800
12 1996 $56,900 $0 $0 $23,900 $80,800
13 1995 $56,900 $0 $0 $23,900 $80,800
14 1994 $59,000 $0 $0 $21,500 $80,500
15 1993 $59,000 $0 $0 $21,500 $80,500
16 1992 $67,100 $0 $0 $23,900 $91,000
17 1991 $66,100 $0 $0 $43,800 $109,900
18 1990 $66,100 $0 $0 $43,800 $109,900
19 1989 $66,100 $0 $0 $43,800 $109,900
20 1988 $43,100 $0 $0 $12,200 $55,300
21 1987 $43,100 $0 $0 $12,200 $55,300
22 1986 1 $43,100 $0 $0 $12,200 $55,300
11
Photos
file://C:\DOCUME-1\miorandd\LOCALS-1\Temp\2F7JV8HW.htm 8/21/2007
Page 4 of 4
�r
file://C:\DOCUME-1\miorandd\LOCALS—l\Temp\2F7JV8HW.htm 8/21/2007
�J � � %��
�oFzt+e ram, Town of Barnstable
hhP �t
Regulatory Services
+ ■pgNSTAM
9 '6SS. �' Thomas F. Geiler,Director
i59. tea,
pl�'0 MPi s
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
- TD
NUMBER OF PAGES TO FOLLOW:
TO: 6 U
a FROM:
4�UA �,Efi
T,
PHONE: PHONE: (508)862-4644
FAX PHONE: `r' FAX PHONE: (508)790-6304
0 Vok
cc:
NOTES/COMMENTS:
Q W x Form.doc
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is Mills
t Marsons MA 02563 June 21 2007
required for �
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
O
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key �j/f 63,5—
to move your David D. Coughanowr �LL
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
VQ 43 Triangle Circle
Company Address
Sandwich MA 02563
'"a" City/Town State Zip Code
508 364-0894 Pending
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the w
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 Aintenar" of on;site
sewage disposal systems. I am a DEP approved system inspector pursuant tojSection_•:.j5.3,&of
Title 5 (310 CMR 15.000).The system: c_ ~
® Passes ❑ Conditionally Passes ❑ hail's �'
11
El Needs Further Evaluation by the Local Approving Authority W
June 21, 2007 ^' rr,
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.
t5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
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:
❑ 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
t5-2661.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�^M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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:
'I ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. CityFrown 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:
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 'h 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.
Lt5-2111.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. City/Town 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-
1 0,000g pd.
❑ ® 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.
t5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�nM 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons M►11s MA 02563 June 21 2007 .
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
SAS also
inspected ❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5-2661.doc•.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
I ,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 114 gpd
9 ( Y 9 (gpd))
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Lt5-2661.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Owner
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age: 28+years. Design plan in owner's possession dated 9119178.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-2661.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection i n Form
p
0
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer appears structurally sound with no evidence of backup or leakage into dwelling
Septic Tank(locate on site plan):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth:
4 in
Distance from top of sludge to bottom of outlet tee or baffle 30 in
Scum thickness 2►n
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 13 in
How were dimensions determined? Design plan
t5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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):
t5-2661.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21, 2007
every page. City/Town 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.):
*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
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 not found where indicated on as built, or by probing or snaking. System has instead been
evaluated on the condition of the leach pit which was located and examined(see page 12).
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-2661.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 37 Chipp 9 in stone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
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.):
Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No
standing effluent was observed to a depth of 2 feet below the top of the leaching pit.
t5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21, 2007
every page. 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.):
1:5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21 2007
every page. City/Town State Zip Code Date of Inspectiori
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.
LOCATIONS
A B C
1 13.5 FE 26 Ft
2 16Ft 20.5fL
3 29.5 Ft 40 FL
l A
SEPTIC EXISTING
TANK o DWELLING
2
# 37
B C
w
Z
J
LEACH
O PIT a
3
CHIPPINGSTONE ROAD NOT TO SCALE
t5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Chippingstone Road
Property Address
Robert and Molly Sorbello
Owner Owner's Name
information is required for Marstons Mills MA 02563 June 21, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: 30+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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 30 feet above
groundwater table.
t5-2661.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
r
Page 1 of 2
06
Miorandi, Donna
From: Ann Quinlin [annquinlin@yahoo.com]
Sent: Tuesday, August 21, 2007 3:40 PM
To: Miorandi, Donna J
Subject: RE: Question on 37 Chippingstone Marstons Mills
Hi Donna:
If you want I can come in in person but if you can help via email, that would be great -(and much
appreciated)!
I have a buyer who is interested in this property but she has a question on the septic.
Here's the town link http://www.town.barnstable.ma.us/assessing/assess06/displqyparcelO7map.asp?
ma-Dpar=027035
The town calls this house a 4 BR, the listing agent calls has it as a 2 BR, the seller purchased the house
as a 2 BR, the septic apparently is sized for 3 BR's.
Here's the big question - could this house legally become a 3 BR? f`
If so, what would have to be done? A
Thanks!
Ann
"Miorandi, Donna"<Donna.Miorandi@town.barnstable.ma.us>wrote:
Hi Ann, It is in the Zone of Contribution on .2 acre. If the septic system is good for three then they are
stuck at 3 bedrooms. If somehow they can prove they legally added on with a permit to 4 bedrooms or
they were ALWAYS 4 bedrooms they they will have to do an upgrade on their septic system to upgrade
to a 4 bedrooms system. Hope that answers your question. Bye for now.
Donna
-----Original Message-----
From: Ann Quinlin [mailto:annquinlin@yahoo.com]
Sent: Thursday, May 17, 2007 12:14 PM
To: Miorandi, Donna
Subject: RE: Question
Hi Donna:
I wonder if you could answer a question for me! I have a listing at 426 Scudder Ave in
Hyannis Port and the assessor's department has it listed as a 4 BR. I remember you once
telling me that the health dept and the assessors dept have different definitions of what
constitutes a bedroom. Thank God I came to check out the septic at the health dept
because I discovered it was a 3 BR septic and the permimt when the current owners added
on called it was a 3 BR.
Here's my question... Could this house (based on the size of the lot and where it is) ever
8/21/2007
r
Page 2 of 2
be able to be called a 4 BR? Here's the link to the assessors page -
http://www.town.bamstable.ma.us/assessing/assess06/displayparcel.07mV.asp?
maip- ar=288010
It seems doubtful to me but I just need to verify!
Thanks,
Ann
Ann Quinlin, ABR,CPS,SRES
Broker Associate
RE/MAX Classic
167 Lovell's Lane
Marstons Mills, MA 02648
508-776-4486
Bored stiff? Loosen up...
Download and play hundreds of games for free on Yahoo! Games.
Ann Quinlin
RE/MAX Classic
167 Lovell's Lane
Marstons Mills, MA 02648
508-776-4486 Cell
866-770-8361 Fax
www.realestatecape.com
!Need a vacation? Get great deals to amazing places on Yahoo! Travel.
8/21/2007
TOWN OF BARNSTABLE
�a
LOCATION 37 Ch1PP;k**S*0Ke 20Qcr •� SEWAGE #
VILLAGE �AQO 5Y�OhS µ; 11 S ASS1✓SSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY •�
LEACHING FACILITY: (type) (size)
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 6f0-feeh Ur15jCC jtoh
LOCATION,
A B C
1 13.5 FL 26 Ft
2 16 FL 20.5 Ft
3 29.5 Ft 46 Ft
,;;;,• A
SEPTIC:I o EXISTING
TANK o DWELLING
2
# 37
13 C
IS
w
Z
LEACH rw
O PIT s l
3
CHIPPINGSTONE ROAD NOT TO SCALE,
COMMONWEALTH OF MASSACHUSETTS
v
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
nl r
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
�e
AP Z�n
-ItiRCEL. DEC 2 1 20 04
-
TOWN OF gF„Y'JS1 ABC E
TITLE 5 "E 'WENT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 37 Chippingstone Road
Marstons Mills MA 02648
Owner's Name: Elizabeth Denneny
Owner's Address: Same
Date of Inspection: October 29,2004 E= —
Name of Inspector: PATRICK M.O'CONNELL '
Company Name: SEPTIC INSPECTION SERVICES CO. f'
± =_
Mailing Address: 189 CAMMETT ROAD v;
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779 r.a
r�
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 DIW
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �����H pF
Passes Oti
Conditionally PassesATRIC N
Needs Further Evaluation by the Local Approving Authority = M ;M
Fails 5
Inspector's Signature: Date: 10/29/04
pF51 SPEG����`�
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health I III
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.
Notes and Comments: Observed liquid level in leaching pit 30" below inlet pipe with no high stains.
Recommend pumping tank.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or 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:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
.pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Titles 2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
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:
se_ The systemp o has a tic tank and it absorption system(SAS)and the SAS is within 100 feet of
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well*". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organi .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:
Titla r,Tnenartinn Rnr All ai1000 3
r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
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 '/2 day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_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.
p p �'Y P PP Y
_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 forma
_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
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.
T41A C rnonantinn 17-411 rPWIA 4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
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
_ N/A 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 f_ P p o o 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)]
Titles G i»cncntinn Rnrm!/I 5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property
p y Address: 37 Chi in stone Road Ma
pp g rstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 1
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):
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): N/A well water. Town water just installed.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Tank pumped years ago.
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_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):
Approximate age of all components, date installed(if known)and source of information:
1980
Were sewage odors detected when arriving at the site(yes or no): No
Tit1P S Tncnp�tinn T:nr Ail siinnn 6
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
p
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line: 8'
Comments(on condition of joints, venting, evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 1'
Material of construction:_X_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5' long x 5.2' wide—1000 gal.
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 11"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Baffles intact,liquid level at bottom of outlet pipe.No evidence of leaks or backup
GREASE TRAP: No (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Titla G inonartinn Fnr A/15/')Ann 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: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (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.):
Single outlet Dipe.No solids or high stains present
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title C incnartinn 17Ar All VIMA 8
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6 pit.
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.): Liquid level in pit is 30" below inlet with no high stains
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY: No (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.):
Titla i Tnenantinn Rnrm All ShInnn 9
I
f -
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
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.
Chippingstone Road
WAS 3 Z7
3�
i
ZO
O
1000 gal tank
1000 gal pit
Titla G Tncnantinn Rn—Ail crnnnn 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 40 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town Groundwater contour map shows water below el.50 and topo map shows property above el.90.
Tit1. C Inennntinn Fnrm 4/1 VIOi O 1 1
��FTHE 1p� DATE
FEE:
� IiARNSTABLE, � '
9 MASS. g,
1639. REC. BY
Town of Barnstable
SCHED. DATE:
Board of Health
200 Main Street,Hyannis MA 02601 '
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,M.S.P.H.
Wayne A.Miller,M.D.
VARIANCE REQUEST FORM
LOCATION r�
PropertyAddress: /
Assessor's Map and Parcel Number: Size of Lot: _0
Wetlands Within 300 Ft. Yes Business Name:
No II < Subdivision Name: p
APPLICANT'S NAME: 2 r10 YGt f u G i I' t i�y' Phone., 5 0? 0 -2 3 0 b
Did the owner of the property authorize you to represent hi4or her? Yes _ No
PROPERTY I � �4!/�OnWNER'S NAME CONTACT PERSON 1
Name: I 0 QNN(N`y Name: D E 3 D R A Il- J C 1I Lil/N 6—
Address: 3) 01 1 NARV,4J I Address: 3�6 dfl
Phone: Jot l J0 3 S-�2% Phone: 5-0? LIvZ? a 3 0-0
VARIANCE FROM REGULATION(Listxe&) REASON FOR VARIANCE(May attach if more space needed)
3J0 em iS 011
NATURE OF WORK: House Addition 13OEDOO House Renovation ❑ Repair of Failed Septic System ❑
Checklist (to be-completed by off ce staff-person receiving variance request application)
Please submit copies in 4 separate completed sets.
Four(4)copies of the completed variance request form G L__
Four(4)copies of engineered plan submitted(e.g.septic system plans) .S6�JG R- Fc7
Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed letter stating that the property owner authorized you to represent him/her for this request
Applicant-understands that the abutters must be notified by`cectified mail at least ten days prior to meeting date at applicant's expense
t` (for Title V and/or local sewage regulation variances only)
" Full menu submitted(for grease trap variance requests only)
Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same
owner/leasee only], outside dining variance renewals [same owner/leasee only], and variances. to repair failed sewage disposal systems
[only if no expansion to the building proposed])
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED Wayne A.Miller,M.D.Chairman
NOT APPROVED Sumner Kaufman,M.S.P.H.
REASON FOR DISAPPROVAL Susan G.Rask,R.S.
Q:\HEALTH\Application Forms\VARIREQ.DOC
�j,•u j 0&
I
January 3, 2005
To: Barnstable Board of Health
From: Mary Elizabeth Denneny
RE: Variance request
I hereby authorize Deborah Schilling, my Realtor to represent me in the request for a
variance on my property located at 37 Chippingstone Road, Marstons Mills,
Massachusetts.
I am requesting the variance from 310 CMR 15.214 to finish a 3rd bedroom in the
unfinished 2nd floor of my 11/2 story Cape Cod style home. The first floor has 2
bedrooms and one bath. The house was bought as an unfinished 3 (or 4)bedroom Cape
in 1980, and we have the following documents from the Town of Barnstable files:
Application for Building Permit, for"4 room"house ("5 room"was crossed out),
Occupancy permit dated May 23, 1980, and certified plot plan, showing house location.
Upon a thorough search of Health Department files, no records were found, even though
we have the Sewage permit number(80-57). We cannot document that a system was
built as a 3 bedroom system,but in review of a substantial percentage of the homes in this
immediate neighborhood (and also within the nitrogen sensitive zone), the homes are
predominately 3 or more bedrooms. It is our understanding that the system that was
installed qualified for 3 bedrooms (at least) in 1980. The practice of building an
expandable Cape was very common at that time that finishing the upstairs meant
additional bedrooms was understood. Because of financial constraints, the upstairs was
never finished since it has been occupied. The house is located within a nitrogen
sensitive area, and since the lot size is .59 acre(25,700 s.f.), it qualifies for only 2
bedrooms under 310 CMR 15.214.
Rationale:
When the current(original owner) bought it, she fully intended to finish additional rooms
upstairs, and always believed she would be able to add at least 1 additional bedroom. She
is now selling the house due to her inability to maintain the property, and to move closer
to her part time job. She has already lost 2 potential Buyers due to the inability to
represent this as an expandable (to at least 3 bedrooms) house.
We believe that the missing records would show the 3 bedroom capacity(possibly 4?)
would have been intended in 1980. We contacted the engineering firm who prepared the
plot plan, and they cannot locate the septic design in their files. They may not have done
that part of the engineering in 1980. We have tried every conceivable means to avoid
asking for a variance, in recognition of the Board's valuable time, and in the interest of
expediting approval of this,but without written documents in the Board of Health, we
understand this variance is the only option.
It is extremely urgent that she obtain this variance, as she is contracted for a reduced rent
apartment in Falmouth, which she will lose if she is unable to sell her house quickly. As
her Realtor, I know her house will sell quickly at a fair market price if she is granted a
variance for the additional bedroom. If she is denied, we have a Buyer who will only pay
75% of its market value, due to the limitation of bedrooms. This will result in a loss of
over$50,000, a considerable sum to a single elderly woman, who still works to provide
herself a continuing income.
We respectfully submit this request and reiterate the extreme hardship that will befall
Miss Denneny if it is not approved. This letter has been prepared by Deborah Schilling.
Respectfully submitted,
Mary E. Denneny ;%7
& -\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
} a DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
. eW
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART-A
CERTIFICATION
Property Address: 37 Chippingstone Road
Marstons Mills MA 02648
Owner's Name: Elizabeth Denneny
Owner's Address: Same
Date of Inspection: October 29,2004
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 Dntttrr►r
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: OF I{qq
__X_ Passes
Conditionally Passes : ATRIC N
Needs Further Evaluation by the Local Approving Authority — M ;M
Fails
s
Inspector's Signature: Date: 10/29/04
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.
Notes and Comments: Observed liquid level in leaching pit 30"below inlet pipe with no high stair.
Recommend pumping tank.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2-of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
--A.- System Passes:
_XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or 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:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Tit1. 9 Tncnortinn T+'nrm /.ii tnnnn 2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require-further evaluation by-the Board of Health in order to-determine�if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well*". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Tit1. Tncn.Pt;— P— 411'�/7nnn 3
L
Page 4 of 11
u OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
D. System Failure Criteria applicable to all systems:
You must indicate' yes or
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 '/z 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
_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 I of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any.portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [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 forma
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
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.
T;NA c i—...f;- Rn-411;nnnn 4
I
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
... ..,w Check if the following have been done. You must indicate"yes"or"no"as to each of the following: 4
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?
_ N/A 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)]
Titlo C Tncncnt nn T nrm�iT si�nnn 5
f
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design)`. 4' Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 1
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):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): N/A well water. Town water just installed.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Tank pumped years ago.
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_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):
Approximate age of all components,date installed(if known)and source of information:
1980
Were sewage odors detected when arriving at the site(yes or no): No
Title C Tncnnrtinn P: ,_All C/7nnn 6
L
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road,Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line: 8'
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 1'.
Material of construction:_X_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5' long x 5.2' wide— 1000 gal.
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 11"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Baffles intact, liquid level at bottom of outlet pipe. No evidence of leaks or backup.
GREASE TRAP: No (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Titic G rncncrtinn Fnr Ail VIAAA 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: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid•level above outlet invert: 0"
Comments(note if boz is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Single outlet pine.No solids or high stains present
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Title C Tncns+rtinn Pn All 8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road, Marstons Mills .
Owner: Elizabeth Denneny +
Date of Inspection: October 29,2004
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6 pit.
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.): Liquid level in pit is 30" below inlet with no high stains
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
Titla G Tnenartinn Pr% m 4/1�;/')nnn 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
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.
Chippingstone Road
_ 33 Z1
3'
t
O
1000 gal tank
1000 gal pit
T:tlo G Tnc—ti— 17-- ail snnnn 10
I
Page 11 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 37 Chippingstone Road, Marstons Mills
Owner: Elizabeth Denneny
Date of Inspection: October 29,2004
SITE EXAM
Slope None
"•: ;
Surface water, None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 40 feet
Please in (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town Groundwater contour map shows water below el.50 and topo map shows property above el. 90.
Titlo C lncnant;nn P—m 411;i,)nno 1 1
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I A , �-,
m / IL
DATA
�jHtq g,Ig BUILO.ASi>8 F.: i 1O9 70O II8. -771Ly 1.386 13 DE1I]SI, YIHCE.a— J Y.I C]�r. ra 7• :.:�. - e�I' ],:,� �. r,. :.:� ;17Os�LI1i2 ';�",""- _.
9
IR
s
s
r ._ r a zc3'.ceo s
a
J8 NI13N 32F88T'f msDATB so F7 =- -- -- 1LL O 3903/2-_----
x�+s to�itw
7"7
Mp 8OO7C/PAG8'
.,�7695 32744/155 12/23/1999 17860 ---- ----- - -- ---- --
No BMR/PAG6
____ ------------ ------------- _
--------------- - r 312.73I 290 �73 OOR79 3/2 2
_ ___ ______- 362,100 COMM FD P_. 0 3
1020 97944 LAND 122 200I LAND BANK i6.38 DENNis, JAMES R
q41. 012-009 L BUILD- 1.879.22, 110 WEST MAIN ST. UNIT
I,k7JNR11Y, TOTAL VALUE 284,300 RE TAX
44 CHERYWOOD Ia DEFERMENT 01 TOT ACTUAL 2,248.33 HYANNIS, MA 02601
MA]<STONS MILLS, MA 02648 EXEMPTION O1
NET VALUE 284,300� LOC: 110 WEST MAIN STR:
BILL
•n :,7C: 4a CHEFRYWOOD LANE EI LL No 77 BOOK/PAGE
15099/064
h RFS
BILL
NO 06
BOOK/PAGE DEED DATE �
7696 $210/175 09/15/1992 1--- ----------------
____,_ D-----
-------------
. --- 339.C]I 196-G23
--------------------- Oi H':FDRE
290-173-00£---_----- 1020 204471 I LAM BUILDING 167,000 LAND BANK 33.12 DENNIS, KEITH 6 LYNETC
DENNEHY, MICHELE M TOTAL VALUE 167.0001 RE TAX 1: . 55 CEDAR STREET
1476476.00
110 WEST MAIN ST X5 I DEFERMENT 01 TOT ACTUAL NEWTON CENTER, KA 0215
HYANNIS, MA 02601 EXEMPTION 0
NET VALE 167,000�-- I LOC; ill ACORN DRIVE
LOC: 110 WEST MAIN STREET BILL NO BOOK/PAGE
33/348
BILL NO BOOK/PAGE DEED DATE ACRES f ---- - ------
7697 13217/273 09/01/2000 ___-__--_________...___________________•-------
__--- 121,400 COI414 FD RE 319.881 216-012
-- --•--_-- 1010 18i567 1 LAND 511.67 DENNIS. KEITH 6 LYNET:
030-030 BUILDING 167,4001 LAND BANK
DENNEHY, SHAWN M S DEAN NA E I TOTAL VALUE 290,8001 RE TAX 1.922.19 55 CEDAR STREET
54 CRANBERRY RIDGE RD I DEFER" 'T 0 TOT ACTUAL 2,299.74 NEWTON CENTER, MA 02]`
MARSTONS MILLS, MA 02648 EXEMPTION 0
NET VALUE 290,800 LOC: ill ACORN DRIVE
: 54 CRANBERRY RIDGE ROAD I BILL NO BOOK/PAGE
48
F-ILL NO BOOR/PAGE DEED DATE SO FI 77-- -------
7698 12094/187 03/01/1999 ----- ------------------------------• •---•-------"'--"-'_--
______________�___-------------- 255.64 C54 024 004
---_-0_________ 1010 171870 I LAID 124,900I LAND FD :E
228-105 BUILDING 124,600� LAND BAN]: 46.16 DENNIS, MARGUERITE
V 6
DENNEN, DAWN D TOTAL VALUE 232,400. RE TAX 1:837.88 DENNIS, MARGUERITE J
473 PINE ST DEFERMENT 0 TOT ACTUAL 1,837.88 2 OLD TOWN ROAD
CENTERVILLE, MA 02632 EXEMPTION 0 WELL£SLEY, MA 02181
SET VALUE 232.400
LOC 90 OLD POST ROA
LOC. 473 PINE STREET BI1l NO BOOK/PACE
SO FT
BILL NO BOOK/PAGE DEED DATE -7709 9665/093
7699 5814/329 07/15/1987 91481 ------------
. --------------------------------------
�85
LAND 353,500 COMM FD RE 756.91� 268-044
1010 202922
1.2 157 136.45 DENNISON, ALLAN G
BUILDING 334,600I LAND BANK 6 !'
DE:7=iEN, EDWARD R 6 CHARLENE TOTAL VALUE 688,100 RE TAX 4,548.34 22 MOHAWK DR
6 TEA LN DEFERMENT 0 TOT ACTUAL 5,441.70 ACTON, MA 01720
OSTEAViLLE, MA 02655 EXEMPTION 0
NET VALUE 688,100
LOCI 5 PRAM ROAD
LOC: 8 TEA LANE BILL NO HOOK/PAGE
BILL NO BOOK/PAGE DEED DATE SO FT 7710 4179/329
7700 13310/224 10/20/2000 30O56 -- --------
------------------------------------
027-035 1010 177909 LAND 79,100 LANDCOMM FC RE 133.65 DENN1 1
DENNENY MARY E - BUILDING 69,700 LAND BANK 21.72 152 LAON, DAMN H
39 CHIPPINGSTONE RD TOTAL VALUE 169, 00 RE TAX 1,342.04 152 LAURIES LANE
MARSTONS MILLS, MA 02648 DEFERMENT 0 TOT ACTUAL 1,342.04 MARSTONS MILLS, MA G
EXEMPTION 0
NET VALUE 169,700
LOCI 152 LAURIES LAN
LOC: 37 CHIPPINGSTONE ROAD BILL NO BOOK/PAGE
BILL NO BOOK/PAGE DEED DATE. SO FT' I 7711 5736/329
7701 C8063/ 25100 -----------
--------------------------- r 1,057.02 249-145
311-027 3530 99246 ;38.300 HYFDR..
DENNIS F THOMAS POST BUILDING 20,700 LAND BANK 441.83 FERRANTI, GEORGE C 6
467 ROUTE 28 TOTAL VALUE 520,700 RE TAX 4,602.10 FERGLEAS ALTO S FR?
::Y•ANNIS, MA 02601 DEFE?MENT 0 TOT ACTUAL 4,602-10 24 GLEASON ST
EXEMPTION 0 ,WATERTOWN, MA 02172
NET VALUE 520,700
LOC: `467 IYANNOUGHv:R6AD/RTE28. 00/PAGF
LOCI 25 S
BILL NO BOOK/PAGE DEED DATE ACRES _^_= BILL-NO; B
--- 7712 'S670/304'
7702 3623/240 12/15/1982 1.34 __________
___
308-182 1010 192452 LAND 73,100 HYFDRE 330.28 310-422
DENNIS, DE3RA L BUILDING 89,600 LAND BANK 32.26 DENT, JOHN W
TOTAL VALUE 162,700 SRCINT 2.23 169 COMPASS CIR
12 DARTMOUTH ST DEFERMENT 0 SRADDED 67.83 HYANNIS, MA 02601
:iYANNIS, MA 02601 EXEMPTION 0 RE TAX 1,075.45
' 162,700 TOT ACTUAL 1,508.05 L•
`. _ '.j .•" NET VALUE F. LOCI 169 COMPASS CI
[,OC: 12 DARTMOITTH'STREET x.•� BILL NO BOOK/PAG
BILL NO BOOK/PAGE DEED DATE ry SO FT I' 7713 15478/OG
7703 12715/339 12/10/1999 5663 -------------------
055-011 1010 189754 LAND 218,800 CTFDP-E 702.54 297-04
:)ENNIS, DONALD A 6 SHERRI C BUILDING 243,400I LAND BANK 91.65 DENT, KAREN K
361 COTUIT BAY DR TOTAL VALUE 462.2001 RE TAX 3,055.14 PO BOX 205
D£FEP34ENT 0 TOT ACTUAL 3,849.33I CUMMAUID, MA 02637
OTUIT, MA 0205 XEM
_ i 0.
EPTION
NET VALUE 462,2001
LOCI 193 PALOMINO i.
:—C: 361 COTUIT BAY DRIVE BILL NO BOOK/PAC
SILT. NO BOOK/PAGE DEED DATE ACRES, - 7714 12917/2:
7704 12235/143 04/30/1999 1.011 -'------' _______-_
------- ---
TOWN`OF BAS ABLE Permit No.
Building Inspector uu Cash
rsu� J'
OCCUPANCY PERMIT Bond
No building nor structure shall be erected, and no land, building or structure shall be
used for a new, different, changed, or .enlarged use without, a Building Permit therefor
first having been obtained from the Building Inspector. No building shall be occupied until a
certificate of occupancy has been issued by:the Building Inspector."
Issued to 'C?C e r .� . I C� r: � Address
q'r ;.�: ;;�4 -�,t-•-f�� ':late� °c•i4'l.�r'`+ .
Wiring Inspector , �'" -' Inspection date y, r
Plumbing I spedtor;` �, i, `' Inspection date
Gas Inspector Inspection date
'Engineering Department Inspection date ...
.f !
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING. SHALL NOT BE OCCUPIER) UNTIL
SIGNED BY THE, BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS.
19.
j,
,Building.Inspector -
L
Page 3 of 6
C. Kieran Healy BSC Group, representing Donna and Jay Sweeney -43
Stetson Street, 12,309 square feet lot, eight (8) variances requested to repair a
failed septic system.
Mr. Healy explained the fourth bedroom was illegal and has been removed. A three-
bedroom deed restriction has been submitted until sewer is available. The septic is
located across the street on another lot. _
McKean stated bedroom 3 needs a larger window.
Mr. Healy explained the new window will meet Code.
Motion by Kaufman /Rask to approve with a three-bedroom deed restriction until sewer
becomes available and the window will be built to Code. So Voted.
D. Peter Sullivan: P.E. representing Kelly Family Realty Trust - 75 Pheasant
Way Centerville, 15,678 sq. ft., new construction proposed, variances requested
in regards to proposed SAS setback to wetland and vertical distance above the
maximum groundwater table elevation.
Mr. Sullivan explained a dormer was added to the attic to create a second bedroom and
the basement will remain unfinished with no windows.
Motion by Kaufman/Rask to approve with a two-bedroom deed restriction and the
drainage easement is to be expunged or relocated. So Voted.
V. Variance Requests:
A. Edward Stone P.E. representing Ruth Boston and Linita Kinear- 18 Spruce
Street, West Barnstable, lot size 18,500 square feet, variances requested to
repair failed septic system.
Mr. Stone explained the latest plan dated September 22, 2004 shows the tank'moved
further from the house.The house contains two existing bedrooms and is in.8 well
protection district.
Michael Rabideau had concerns with the proximity to his property.
Mr. Stone explained it will be 1.4 feet from the closest point to the wall.
Motion by Rask/Kaufman to approve with a two-bedroom deed restriction. So Voted.
%— B. James LeBoeuf representing Melvin and Virginia Reed--162 Cinderella-
Terrace, lot size 0.46 acre, existing two bedroom home located within a nitrogen
sensitive area, requests a variance from 310 CMR 15.214 to finish second floor
for a total of four bedrooms.
Mr. LeBoeuf explained the property was bought as an unfinished four-bedroom that was
,1 built in'-1983•and finished in"1984
' McKean stated the building & health departments have no records on the property. p
Rask explained the 330 ordinance exists. The home could be finished as a three- J.
bedroom at most. One pit is adequate for a three-bedroom.
Motion by Rask/Kaufman to approve the expansion to three bedrooms with a three-
bedroom deed restriction. So Voted.
310CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION
15.213: continued
(g) any portion of the soil absorption system that is within the velocity zone or regulatory
floodway is a leaching bed or trench system or any other system constructed in
accordance with the wetlands protection act and 310 CMR 10.00.
15.214: Nitrogen Loading Limitations
(1) No system serving new construction in Nitrogen Sensitive Areas designated in 310 CMR
15.215 shall be designed to receive or shall receive more than 440 gallons of design flow per
day per acre except as set forth at 310 CMR 15.216(aggregate flows)or 15.217(enhanced
nitrogen removal).
(2) No system serving new construction in areas where the use of both on-site systems and
drinking water supply wells is proposed to serve the facility shall be designed to receive or
shall receive more than 440 gallons of design flow per day per acre from residential uses
except as set forth at 310 CMR 15.216 (aggregate flows) or 15.217 (enhanced nitrogen
removal).
(3) It shall be the duty of the owner of the system or proposed system to ascertain whether
or not the facility to be constructed will be in a nitrogen sensitive area. The Department will.
prepare and make available at locations generally accessible to the public maps portraying
designated nitrogen sensitive areas within the Commonwealth.
15.215: Designation of Nitrogen Sensitive Areas
The following areas have been determined by the Department to be particularly sensitive -.
to the discharge of pollutants from on-site sewage disposal systems and are therefore
designated nitrogen sensitive.The necessity of providing increased treatment of pollutants
and reduction in nutrients discharged from on-site sewage disposal systems,*including
nitrogen, nitrogen as nitrate, phosphorous and pathogens in these areas warrants the
imposition of the loading restrictions set forth in 310 CMR 15.214.
(1) Interim.Wellhead Protection Areas and mapped Zone Its of public water supplies as set
forth in 310 CMR 22.21;
(2) Nitrogen sensitive embayments or other areas which are designated as nitrogen sensitive
for purposes of 310 CMR 15.000 shall be mapped based on scientific evaluations of the
affected water body and adopted through parallel public processes in both 310 CMR 15.000
and in the Massachusetts Water Quality Standards-314 CMR 4.00.
15.216: Aggregate Determinations of Flows and Nitrogen Loadings
The 440 gallons per day per acre nitrogen loading limitations imposed by 310 CMR
15.214 may be calculated in the aggregate in the following situations:
(1) in identified areas within regions or communities that have submitted to the Department
a plan to protect surface and ground-water supplies within the community or those designated
areas from pollutant and nutrient loading and.a proposed mechanism for:implementing the .
plan and where.the plan has been approved in writing by the Department. For areas that
include Zone Its or Interim Wellhead Protection areas, the plan shall include, but not be
limited to,a nitrate loading plan as specified in 310 CMR 22.21(2)(d);or
12/27/96 310 CMR-514
1—
i
Home: Departments: Assessors Division: Property Assessment Search Results
37 tCHIPPINGSTONELd 1R®AD
Owner:
DENNENY, MARY E Property Sketch Legend
Map/Parcel/Parcel Extension
027 /035/
Mailing Address
DENNENY, MARY E
4
39 CHIPPINGSTONE RD
MARSTONS MILLS, MA. 02648
2005 Assessed Values:
Appraised ValueAssessed Value
Building Value: $97,500 $97,500
Extra Features:$0 $0
Outbuildings: $0 $0
Land Value: $ 128,300 $ 128,300 Interactive Property Map:Map requires Plu in:
Totals:$225,800 $225,800 I have visited the maps before _ �tC�Lo First time
Show Me The Maa M1 Click h
April 2001 photos available
Sales History:
Owner: Sale Date Book/Page: Sale Price:
DENNENY, MARY E C80634 $0
2005 REAL ESTATE Tax Information: Tax Rates: (per $1,000 of valuation)
Land Bank Tax $40.98 Town Fire District Rates
$6.05 Barnstable-Residential $2.12
Barnstable-Commercial $2.80
C.O.M.M.FD Tax(Residential) $228.06 C.O.M.M.-All Classes $1.01
Cotuit FD-All Classes $1.28
Town Tax(Residential) $ 1,366.09 Hyannis- Residential $1.52
Hyannis-Commercial $2.39
W Barnstable-Residential $1.44
W Barnstable-Commercial$2.10
Total: $ 1,635.13 Due to rounding differences these values may vary
Land and Building Information
I�
Asses' .......... SEPTIC SYSTEM MUS7 LiU
Assessor's map and lot number .......
INSTALLED IN COMPLIA THE
Sewage Permit numb r ..::7... ... ........................ WITH TITLE 5
ENVIRONMENTAL COD
11AR3MIL 1TABLE,
House number ..... ..... ................................................... TOWN, 0
WTI X2639 N
TOWN OF BAR' N' STABLE
BUILDING -INSPECTOR
APPLICATION FOR PERMIT TO*............AV tke.&.......................................................................................
TYPE OF CONSTRUCTION ..........WAN....... .M; ......................................................................
. 4 /j ,e ........... ../....... ......
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ..........C,
.8.MA1Nz;,
......... 10. ......1.(MXLQAW.....11VI4 1w.X
ProposedUse ...... ..46S..............................................................................................
District .....Zoning District ......1.
..............................................................Fire C .....................................................
Name of Owner ....Address ........ ..A.At..........
Name of Builder A1.LL.,9...................
Nameof Architect ...............N.ON.46............................Address ....................................................................................
q
Number of Rooms .....................A........................................Foundation .... ....
Apvfiz-4.......C4.1vtom.
..................
Exterior ...... ...........................Roofing ......pd!!
..#4/�.r....S#1N.
Floors ..................................Interior ...........
Heating ...Aot!! :..................................Plumbing .............. ....................................
Fireplace ..............IOVOA4 .....:.......................................Approximate Cost .................oetv...41..... .......
Definitive Plan Approved by Planning Board ----------------------------- Area ........7 .........
Diagram of Lot and Building with Dimensions Fee .....................3....................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
q q
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name y4ad.,.... ..............
I
45
o
J o 6
Co Q LOT 4 6
-' 0 4 7
\STo RY
WOOD
HOUSE 4Z1+
------------------
J 1
1
S i
1
112.00
1 =
CNI PPI NG5TON E ROAD
PR I YAT E - 40 ' WIDE
I CERTIFY THAT THE POU5E /5 LOCATED 95 WE ,6
61 P 5URVEYdq
REFERENCE: L.C. 348468
PLOT P L A N bolme s and mmgra th, inc.
5HOWING H005E LOCATION FOR c,v,j `nq;:7eers o,,»iond sur vt"L "" '$ ".41 P y
1N '
M A RSTON5 M 1 L L5,
I
TOWN OF BARNSTABLE
LQCA 1'-'IS 32 &a '2,R d Y,�mL �'�Q SEWAGE #J i�S?K:i►'c?:�
VILLAGE 0 0, 51v:A5 Milts ASSiv- .ORS JMAR& LO.T®2'7 035
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I10C20 �
a I
LEACHING FACILITY: (type),,—�,,>�T (size) `+
NO. OF BEDROOMS Z
BUILDER OR
PERMTTDATE: C dhiC-E, DATE:.a- -lf 0:-\ 101Z910
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
a
Z�
3�1 Lo �.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
H
............................Town..o F...Barns tabl e.......
k
.gip iration for %posal Vorkfi Tow1rurtivtt 1hrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System.;at:
._..Lot # 46 Chi�pingstone Road Santuit
....._�._.._.. ...... .... ...........•....• ••-•-...•----------------•.....•----•----•-•--................---•..................••••...........
.Locat' Address or Lot No.
.. Jordan Realty trust Hanover, Mass.
...................................................... •-----•-•---•..................................................-•-........_.............
owner Address
a M and B Builders Hanover, Mass .
-------•--••---------------•-•-------•--....---. ............------....---•----•--..••-•-••...... ........-----...............•-•-•....•-----......---....................................
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
aOther
—Type of Building ............................ No. of persons._...=..................... Showers ( ) — Cafeteria ( )
d Design Flow.Other fixtures•...5�.__...__gallons per person p r day. Total daily flow.........................3GO
W -•--------•-gallons.
W Septic Tank—Liquid capacityl+00�allons Length..
-------------- Width--------------._ Diameter................ Depth................
Pit No..................... Diameter..............._.... Depth below inlet................. Total leaching area ..................sq. ft.
x Disposal Trench—1................ . Width............__._ Total Length...._..--.---• Total leaching area...................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil
...PercoYatioritests .arid .soil...Io s on- iTe--wt....•..----'-------"•--•'•-•----•--•--......
-------------------------------------------------------------------------------
--...........
---------------
x health--•of`�`io e....._....-•--..
W ...............................................•-••-----------•--••-•-••-------------------•---•----•-••-------••-•----•--•----•-------•-------•-•-----••--•------...----.._..----•---••-----------.-----
------•--------------------•-------------•---------------------------...-------------------------------------------------------------=------•--------------•---------...--------------.........--•-----
V 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued�y liu b �fe p
Si ed �....................... x:..... :!1.."....`....
Da
Application Approved By.. ".. . ,....
c, a
Application Disapproved for the following reasons---------------------------------------------------------------------•----------------------...--••----••-•••....
----------------------------------------------------------•----------------------•-------•----•---------------......----••-----------------------.-.---•----••••-----••-----1_- ....................
Date
PermitNo......................................................... Issued...........................................................
Date
........ .................................................................... .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
..............O F.....................................................................................
f9rdif irate of Tompliatur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( )
by....... I+_and B Build.ers
: ............
--------------------------...........
------------------ -------•------------..-----------
•-----•. .......
Ins ler
at................Lot # 46 Chippingstone Ad. , `antuit
. ..... . . .............••----••••---••---•------.....------••--------•••--------•••--------------••-------•-••-------••--•---•-----.
has been installed in accordance with the provisions of Article XI of The State Sanitary Code a desc ibed in the
application for Disposal Works Construction Permit No....._... ________________ dated___-. .-...--_----
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.... ..
DATE................................................................................ Inspector.... .....---•-•- -----... ......----- ._..... ...........----
-
.................................. ............................................................:....... ...................:...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF' HEALTH
Town...&F.....Barnstable
--------------------------------------•..........
No...�. ...... FEE...or�..............
Uisp anal Works Tonstrt iott ramft
Permission is hereby granted.....1X.... 11d..B.....Bulld-e.n5.........................................................................................
to Construct (X ) or Repair ( ) an Individual Sewage Disposal System
at No.......La.t.. ...46...QW-ppingat.ome...hoad.....5antui-------------------------------------------tb�/
Street as shown on the application for Disposal Works Construction rmit No.. C ate •-•.-
---• ...... .. . ....
Board of Healt
DATE-.................................................................,..: .--•----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS'
LC
a
p
1 oco GA _ 1/ Q'
W HOME
Alo
. N
IIZ. oo il
4 � Sc�ic' -� l'' 4•G=' -- Sep �t-I��.�,�c� ���� �
No...........�,.er....... Fxn..1P,....................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................Town..OF....Barns.table............................................................
,AppIirofion,for Disposal 10orkii Tonotrnrtioaa Permit
Application is hereby made forda.,Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
..•...Lot ` 4h.-Ch p in stone Road. Snntuit
.. ............. ....................................................-•--•---...................................._.;
Location-Address or Lot No.
... .Jordan He€�;lty.Trust - Hanover, Mass.
_.._.._.__..... --•-- - ---------------•• ---..........._.... ..
Owner Address
W M and B Builders Hanover Mass.
a Instal ................................•......... •••_•_.... ............'---••-•--..._...-W es............•-•-.....................•••_....
� Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms................... .._._..__..._....._....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............_............... Showers ( ) — Cafeteria ( )
Otherfixtures -•-----------------------------•---------------.._..--••-•-----•-•--•••••-•-•••--------------......•••-•-........._.•--•--
0.0
Design Flow..............................�� ........gallons per person p r day. Total daily flow................ 3...............gallons.
W4
WSeptic Tank—Liquid capacit} �__._._ allons Length................ Width.............:. Diameter................ Depth................
x Disposal Trench—No..................... Width_..__....__........ Total Length..... .......... Total leaching area....................sq. ft.
Seepage Pit No......... Diameter...... ........... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-, Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. 1................minutes per inch Depth:of Test Pit.................... Depth to ground water........................
w Test Pit No. 2................minutes per inch Depth of w est Pit.................... Depth to ground water........................
rx
Description of Sol l...Perco`La.t ori'•tests iiK3" s il---T6gs--•ori---file-•at•... ...................................
xhealth.&rf is"e---------------------------------......---------------------------------------------................._..-------
U .-•--.........••-•-••-•-•---......••---•••-•••....---••--•---•.........•-•••••-•---•-------------•---••..........-----•-•--------•••-
UW •-•----••-••••----•----•-••----••--••--••--•••-••---•------•---•---•••••••••-•-•••----------•-•••-••••--•------•-----------------------••-•••-•-•---••-••-•-•._...•••--•-•-•._......••..................
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beqn isptd�y e�i fe _ r 4
Signed
_ ' rl � ....................................
., ...............................
�°.` . rE . .
D)a
Application Approved B ......' � .................................. �Date
Application Disapproved for the following reasons:------•••--- ----------------------•-----------------------------------------...-----..._.....•••......:_......
......-•-._........-•••-••••-•-•••••-•-••.........•---•••..........-•••-•••••-••••-•-•••-•••••............---•-•----•------••----•-••••••-••••••-•••--•-•-•------•-•-•••-•-•-•-•-•----••---••-...:..-•-•-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
........OF.....................................................................................
Trrtifiratr of Tompliaanrr
THISJS TO C- TIFyY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( )
;v and L,�j ld.ers
by ............................ •...........
*•-•....-•••-
at Lot # 46 Chippingstone :tad . "S14tituit
.._.. -•••----------•-------
has been installed in accordance with the provisions of Article X'".�o The State Sanitary Code as des ribed in the
application for Disposal Works Construction Permit No.__.__...v� .. .................. dated-__ !'1... /_s':`=:_._.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE-CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. - ...... .---•--------------------------•-_... Inspector..... ` .......... ..: _.`.."_.."."-....... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
NO..°'.':_. ..... _ . .................................... OF................•--••-•.....-••-•-...................................._......-• FEE.: °.........` ..
Ditipopa1 Works Tonstrnrtion Permit r
M and F Builders >�
Permissionis hereby granted..............................................................................................................................................
to Constr ct R ) an ndividual Se ages DIs o 1 System
' obip(pina sone rcoac .pan$ui t at No................................................................................................................................................................................
.
Street
as shown on the application for Disposal Works Construction. Kermit No ._/.� Patec.__..'',�'`_s . `••• "�:;-
J ......
...........h........ .... .
DATE................................................................................
Board of Health �-
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
a� Lot 45
V �
V
s
0
0
1-ot JA 47
IS e
60e
t
3a� (n
goo 24 ¢
Q
N
IIZ. 00
Chi PP<NGStoN R- ROAo
Sc�►� - O= 401 — SeQ Aa4 c�,ed L�Q �►r r
---- Fee------------ -- ._...
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application forlVell Congtrurt ion Permit _
Application is,r hereby
]Cmade for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
—
Location - Address Assessors Map and Parcel
- - ----------------------------
/� Owner - n ' Address
--- /:b c&Y �Gc� -"aS .� -vl,``� DD6
---------------------- ----- --------- ---------------------------
Installer - Driller Address
Type of Building
Dwelling ° s 2- ---------------------------------
Other - Type of Building----------------------------------- No. of Persons----------------------------------------------------
Typeof Well--Y--19J( ------------------------------------------- Capacity ----------------------- -----
Purpose of Well 0�'_``�S?`=`- � i ----------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificat .of Co pliance has been issued by the Board of Health.
Signed -- ---- - - - - ------ JAI-
date q
Application Approved By- - Q - /� --- t
ae
Application Disapproved for the following reasons:-----------------------------------------------------------------------------
---------— -- — ----- -------------— --------------------------------------------------------------------------------date----------------
PermitNo. -— -- - -- ------------ Issued---------------------------------------------------------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired
bY------------ -- - A_S cc� �� l/
--------------------------------------------------------------------------------------
--- - --------------------------
Installer
at- — = c of.,} S 7'0`.'� —'�—�—�' —— --— ---------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. --------------------------Dated------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------- -—-- ----------------- -- Inspector--------------------------------------------------------------------------
i
9� 1
---- Fee--�S---------- -
BOARD OF HEALTH
TOWN OF BARNSTABLE
DPP Ica ton I[Con5truction3permit
Application as hereb made-foj4yermitt to C�onstruc (° ), Alter( ), or Repair (")an indiv al Well at:
ocahon Address Assessors pan Parcel —
P
Owner _' Address
-
n r
S u w: r -----------------r--� -- ------ ---- ----- �"- j�G '``'s ue`- --- --�,:�6 ,/(_- t G
Installer - Driller j' Address "'f`
Type of Building --
Dwell.ng 1 f°� s F.2
;
- »
,,.
_'l--,"Other - Type of Building---- -------- ------ ------ a �°No. of Persons--- ------------------------ ----------------------
Type of Well- Y -��G�_- -- --------- -- Capacity
------------ ------------- -----------------
Purpose of Well�o----- 7°`
Agreement: 8
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private--Well Protection Regulation - The undersigned further agrees not to
_. I
' place the well"in operation until a Cert7;7
pliance has been issded-b -the-Board-of-Health:
4
Signed - date
` J
AA a
71)
Ap ion pprove y -�—- - -,,- T-T Ale '
Application-Disapproved Eor"the following.reasons: j
-----------—-- ---- ------- — --------------------------------------------------------------------------------------------------
date
Permit No. --- --- -�-----
---------------- Issued------------------------------------------------------------------
_ .. . ,. .. _. .>. date
t19 e (l
3 � . .
,STvr C �
i
14
BOARD OF HEALTH_-
TOWN OF BARNSTABLE
Certifuate Of Compliance
; .
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ), or Repaired (� ,
e�.��,� // -- - - — ------------- -------------- —
y— D A S Installer
!.. G , r '
m
at- -`3_� P/V 7-6 - "� -�-- — - - —
has been installed in accordance with.the provisions of the Town of Barnstable Board of Health Private Well Protection 1
Regulation as described in the application for Well Construction Permit No. ---------- =-Dated--------------------
:h,fFe..ir....:. -
THE ISSUANCE-OF THIS.t CERTIFFk:ICATE SHALL NOT BE CONSTRUED AS A-GUARANTEE THAT THE WELL '
" SYSTEM WILL FUNCTION SATISFACTORY:
-— - -----— -- Inspector-
BOARD
DATE------------------------—------ - �----------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE � ;F
w VrIt Con9tructionPermit
1
No. W__ - ------ Fee-T---------------
Permission is hereby.granted----- -- - -
to Construct ( ), Alter ( ), or Repair ( "I'an Individual Well at
-=
can -- -
t ,
— Street
as shown orl the anolicatiqq for a Well Construction Permit
,
Dated - - '° eJ Q .
------- --- ------------------------------------ -
_/ —�,. -e+—. •�c,.q:_.� _-"'•-:».. -.-,5- - -'�-rmss�.oxs' M^...1..•-w''-�•...— .---s+�.-s.,..•.s.--e,_:-...x-. - —
f HeaJ�t T
rU o
fe OF ExI5TIN6 WINDOW fL OF ExI5TIN 11.E6 WINDON - y
_ YI Y1
I I
"--------------------
N N
X om U 61 Q N
Y
I
i
-
g
V!
' ---------•EXISTING ft1E LK
LOCATION TO REMAIN _
EXISTING CELLAR SASH A5CCM-2149 ' 0
NS LOCATIO TO REMAIN e 4 x - 314
L
NEW 3 In'DIA.STL. EXISTING Fp14DATION WALLS O W
COL.ON ax2aX-2 cDNc. BATH. ASC N-B
FoonNG�c A.A,ovE O ^ BEDROOM 2-q 9/ xa-I /a U
Ex15TINb SLAB AS NEEDED) [111
- - - -EXSTING BEAM AND 9
COLLMNS TO REMAIN
ISTING BASEMENT _,..••''J�� U
LU
(ALIGN W EDGE OF CO.ABG/E)
-- 2-IO In%b'-10 V2 P.
—o— o — 4
EXISTING WALL,DOOR E I 0 E
• MOVED AND REPEALED NV NEW
CA9ED•OPENIIRi PROVIDE(2113/4' L O J
%II I/4'lVL
POST DOWN O NEW CD.
1;
z-a ASC z4n 3/a DINING LIVING ASLON-3359
8 2 34 X4-II /
g _ ••�' REMOVE EXISTING MALL
NEW;TREADS,RISERS, 3
-- O NAALPL TELL TO BE I EDA"D
i x
m � ,
i
W
pa
FOUNDATION PLAN
SCALE: 1/4 1'-0' is me n zm
O
I
fE OF EXISTING WINDOWS fr aF Ex15TING WINDOWS
ALIGN IN 4 OF ALIGN W/ OF
WINDOW BELOW WINDOW BELOW
FIRST FLOOR PLAN
"ot-o-y o�d_rQ nn pQ�;c
am A am s2�'�a�as��o6mu°'v=o
n C Y ---ry jia��vQ°f =0- �ry
J Up00 <�SsO Jn66
0
ao;r� � osLLEu_o '"m
5a
~m
__--------
�� _________ _____ CJ-G.LINE
4 BATH.
9'-2 3/4' 1�-4 In' s'-b' Q 10'-T IM,
- ---- -------- ------- -
----------------------
W N
_ P
-- OFFICE �;.p WALL/DEMO z
Cl
10'-1114' 0.(�
REMOVE EXISTINb WALL�m �'� = W 1-5 AND ITEMS TO
WVW FIN.OECORATIVE LD. -----'
BAWSTERS NEWEL POSTS.AND m BE REMOVED J
=9 ON-33g3 HANDRAIL TO BE INSTALLED ° E BEDROOM 2 A5LON-3353 W j)
4 9 3/6 X 4-s 3/ EXI5TING WALL5 TO lNL
P REMAIN
i - V
CLb.LINE a LLb,LINE � NEW WALLS Q Z In
o DEMO NOTE5 CL Z'IJ a-t Q
EXISTING OASIED WINDOW5 4 WALLS `�' r
a -_-_-_-_ _______ TO BE REMOVED AND PATCHED AS NEEDED
OR REPEALED AS NOTED. LL
Q m LL
________ ____a___ _________ __________________-________ _________. Job no.: 0421
�c m� '/� ■^/ /'/t/1 AA G l/� dote -NNE b,2005
MN 2. scale AS NOTED
/Y\��✓61�� YYY 1 !!! dreun KMW
112,•/- 9'-5 In,
3
W
ev.
ALIGN W/fe OF ALIGN W/CL OF °�-O
Lo WINDOWS BELONI WINDOYS BELOW 0 O
Lo SECOND FLOOR PLAN °ry
O SCALE: 1/4' - I-0- w
m
m
M,t: of
A AND REPN IN
REMOVE LACE W�NKalES V "1 O Q
A-3 GAF TIMBERLINE ULTRA V• I(� �I�
ASFNALT SHINGLE RI S W/
WNTINJOY ROSE VENT Ull
I] NON-B)ILT-OUT II
IX3A%B RARE tRJ QB•/- / e •/�
REMOVE EXIST.SHINGLES IOD Ix BLOCKING , N U f\
AND REPLACE WITH
OAF TIMBERLINE LLiitA
ASPHALT SHINGLES W/ IXb CORHER50ARD5
ID
LOMINLIO,15 RIDGE VENT ® ® \ , `�1(1
N.C.SHINGLE$ �10 IXb fSRNERBOARDS � :Y
A-3 WWBJILI� J
REMOVE EX15TIN6 5WNSLE5 1X5/IXb RAKE ON /
AND REPLACE WITH L. IX 51.00KIN6 V
REMOVE EXISTING SHINGLES c 10 I� SHINGLES
AND REPLACE WITH C. 1/
SHINGLESJU
SLE F��R e SECOND
LOOK(E%ISTI�i'I— — SUSIfL ftR. , ' a1
REMOVE ALL EDOU56ININ S
WINDOWS(FRAME TO FIT ® CUSTOM DECORATVE {
EXISTINb RC,HEIGHT: BRACKET REMOVE Al-L EXISTING rvINDOWS 1:
PATCH AS NEEDED) �-i 1 REPLACE W/DOUBLE-MRJG
EXISTING RD.HEIG T FIT U 0
CORAERBOARD5 P1D REMOVE EXISTING(SAND PATCH AS NEEDED) S
STEP$AND LIM PE ANp
COPRtERBOM09I REPLACE N IX4 ICE L U 7
DECKING ON P.T.FRAME
(a TREADS) CORNERBOAR�ANDA�REPLACE W/IX5/Xb
`JB FLR O FIRST SU8 F R
EXISTI — _
FIR i FLO 1-1
OR
1 O CUSTOM DECORATNE
BRACKET _ EXISTING SLLKHEA[7
._______ TO REMAIN
REMOVE EXISTING CONIC.
5TEP5 AHD LANDING AND , _
REPLACE WJ 1X4 ICE EXISnNS CELLAR
DECKING ON P.T.FRAME SASH TO REMAIN
(I4'TREADS)
FRO N T EL E VAT I ON R I G HT E L E V AT ION
SCALE. I/4- 1-0-
��'Y U�UNiI T �"(iOUm
3`n��uox n-'am a
zzoo „P�ogoN5�o0m °'o=`on
REMOVE EXIST.SHINGLES A W; REMOVE EXIST.SHINGLES y m T9,0 m L c S 0 0
QQ
AND REPLACE WITH -3 Y ��0�� a E
6AF TIMBERLINE ULTRA �; AND REPLACE WITH $I �.. yn O u 0 U=0 O
ASPHALT SH 6AF TIMBERLINE ULTRA B _ cc
CONTINXAfi RIDGE NT
INGLES ASPHALT SHINGLES W/ r Q fr a Q y 0
GONTINXXY RIDGE VENT 12
I A4, _
KC.SHINGLES n-3 NpN-BIiLT<VTQ o o.L,V 5 i Q E 11 _O-O U
IXBAXb RAKE ON
IX BLOCKING
IXB CORNERBOARDS IXb CORNERBOPRpS ID
W
WC.SHINGLES 11'
REMOVE EXISTING 5HIN5LE5 •�. ,(�
EH AND REPLACE WITH WL. I A•9 NX3/IXB RAKE ON
' IX BLOCKING \7 L J
LU
`�"FI FLOOR — 6..wFIRiT iIOOR W J
REMOVE EXISTING 5HIN6LE5
\ , AND REPLACE WITH A.C. V
REMOVE ALL EXISTING WINDOWS / SHIN6LE5 W
1 REPLACE W/DOLELE-NA16 O ,n W
WINDOWS(FRAME TO FITFIM V 1
EXISTING R.O.HEIGHT:
PATCH AS NEEDED)
REMOVE ALL EXISTING WINpOWS �O�DEfSRATIVE
1 REPLACE W/OCLELE-WN6 REMOVE EXISTING IX4A%5 REMOVE EXISTING LOAN.
W ISTINS RD.tFR HE TO FIT CORNERWARCS
AND lNL \1 InL/
EXISTING RA.HEI6M: REPLACE W IXS/IXb
PATCH AS NEEDED) CORNEREOARDS p STEPS E LANDING AND
II IIIIrI�1111I RECLINE VU Ixd ICE
�_S.UB FLR. LU
DECKING ON P.T.FRAME O ^�( v
Q e FIRST FLOOR SUB Fy2 (14'TREADS) 1 �l
�o FIRST FLOOR m IL
REMOVE EXISTING IXAAXS
CORNERBOAROS EXISTING BUI�KIEAD b ro
REPLACE W 1X5A%6 .__________. LO REMAIN _______ J- .. 0521
CORNERBOPRO` :
EXISTING EULKIEAD -_-- date DAME Ob,2OO5
EXISTING BA.KHEAD
i0 REMAIN EXISTING CELLAR tale q5 NOTED
SASH TO REMAIN
KMW
REAR ELEVATION LEFT ELEVAT ION drown
SCALE: I/4- a 1-0' V
SCALE: I/4' I'-O-
3 V
w
j e.
�O
01
ry O�
gw A-2
N�
Ott; of
RIDGE VENT LAP
2X6 RIDGE BOARD 2X6 OILS,JOISTS 0 16'OO. GAF'TIMBERLINE'ULTRA I I
INEIGNT TO MATCH EXISTING) ROOF SHINGLES ON
IS FELT ON 5/B'OD% N
WC.FOOF PLYWD.S
SHIN5LE5 HEATHING
5/B•CDX FLYIN2OD I I
2%6 RIDGE BEAM WL.ROOF 5HIN6LE5
2X6 RAFTERS 0 V OL, j/X66 RAFTERS.6D O.C. I``�1
R-30 FG.INSULATION
2X4 CL R-3
&JOISTS OL6.JOISTS OL. Q 0
-30 FS.INSUATION �I� TIT
012'GYP.BOARD TO .�5 O ON
MATCH EXIST,") IX FASCIAIA ON
� uJ
12 I%BLOCKING �'^1 a1 _
W
K�EE MA-Li 19 VO MER /
MA LH EAASTING) , REMOVE EXISTIM SHINGLES
AND REPLACE ATN WL.
\ SHINGLES
WC.SN"%LES TI 1p1F1
1/2,COX PLYWOOD 2%4 0 16'OL. EXISTING FASCIA/ "T
5 I LLL
R-15 F.G.IN5AATION GUTTER TO REMAIN
I/2'GYP.BOARD BEDROOM
?
4 1 REMOVE ALL EXISTING WINDOWS
REP W/ v
U LACE DO.BLE-WINS
•9 WINDOVK IFRAFE TO FIT 1.1
EX15TIN6 R.O.HEIGHT•
PATCH AS NEEDED)
TOP OF 1` I�TV`1 Il\`fY11
VIAE V
IX CAP SHELF 2
YV ALUM.DRIP EDGE
m �
� � LIVING R BEDROOM
U s f
°l iB AAOWN ON U I
wB FLR l0 u
O FIRS—TTLOOit
I V4'
I%6 EOGE 1 CM.BEAD BOARD
EXISTING BEAM
REMOVE EXISTING WALL BASEMENT EXI5TIN6 HOUSE
NEVI TREA05,R15ERS, CISTOM BRACKET
BALUSTERS.NEWEL FOST5.
AND HANDRAIL TO BE
INSTALLED NEW 31/2'DIA STL.
COL.ON 24X24XI2
T T
R INNCP%OOTIN6E LAB AS�NEEDED) S
�OP OF FOOTING .1 1 1 1
(EXISTING) .... .... .. .. T K
b
Q
SECTI ON
SCALE, I/4' 1'-O"
OEAVE DETAIL AT COVHD. ENTRY
SCALE I I/T.I'-0' tp,-p•,�o Q`o Ptiyg Pas `pp0
��.L Y'QD�lpma'C
�p
� <pio
' n'Y�p�ps�`Q`a➢Oo�Ocp -
u O..W.p~QI"➢
$o�ooa o�<<6�o�$S�a➢
pU-p`cIN
F p '^➢ 0
ra yr
12
6AF'1I1BERLINE'IATRA / GAF'TIMBERLINE'U.TRA LU
ROOF 5HN6LE50N 10� / ROOF 5HINGLE5 ON I 12 6AF'TIMBERLINE'ULTRA ` fl J
15 LB.FELT ON 5/8'CDX / 15 LB.FELT ON 5/5'COX Q 3•/- I�FELT ON 5 IN&LES ON 8 COX Z
RYWp.5HEATXIN6 / RYWD.$HEATMINS Q y Q
PLLB.F LT ON NG L
LU
12 W
2X10 RAFTERS 0 16.O.L. I� —— 2X6 RAFTERS O ib'O.C. 1O,n Q
2XB RAF .W OL. /'� ALUM.GRIP EDGE V'V�1 Z
2X4 US JOIST5 0 V 0 C. (\/1 I
ALIM,"TIER(CANT)
ONI%FASCIA _ ^ 1X3/IXB FASCIA O Z,n
IX CAP SHELF V 1 W
W/ALCM,DRIP EDGE a-
(3E ¢ IX SOFFIT
FFIT 2"/VIDE 1.(T Z
IX SOFFIT W/CANT. •bOO5 GROWN ON— p m 0@S m LU ll I
IX SOFFIT W/LOM. I%FASCIA Q p{ U( < p
S •6003 CROWN ON w
.B003 CROWN ON `y IX SOFFIT W/CONT. p t r IX FRIEZE 80ARD .("% IM ILL
IX FRIEZE BOARD / S U� FERF.VENT 2'WIDE p Q t f- t- ON Ix BLOCKINS V \I 1
ON IX ELOCKINS T SZ
6•
-8003 CROWN ON Job no.: 0521
ZX TAPERED OM J IX CA51%(3-EXP) Q I%NE cm—
W/(4 1/2'EXPJ
BOIb BED MOI,LDIN6
date JJNE Ob,2005
' ON IX NEAR CASING
(4 A/2'EXPJ 7 Ev91'
acal0 A5 NOTED
OEAVE DETAIL AT ENTRY O EAVE DETAIL AT GABLE DORMER O EAVE DETAIL AT BEDROOM/BATH./OFFICE KMW
SCALE,1 1/2".V-O' 5CALE,1 1/2'.V. ' SCALE,1 1/2'.I•-0-
3 ems.
. w
j e.•.
�O
� OO
w A3
8 �°
a
eM: Ol