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HomeMy WebLinkAbout0060 CHIPPINGSTONE ROAD - Health (2) 60 Chippingstone Road m Marstons Mills P - A 027 044 Ali J Commonwealth of Massachusetts . da �0�7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Chippingstone Road M SVe e 4 Property Address Brigitte& Ryan Devincent Owner Owner's Name information is Marstons Mills required for every Ma 02648 3/26/2018 'X! page. City/Town State Zip Code Date of Inspection :. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information A filling out forms �/# ��/6� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name �� 74 Beldan Ln. n Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@g mail.coin SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/26/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ��c�V'S r Commonwealth of Massachusetts r Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.3,03 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 60 Chippingstone Rd Marstons Mills is served by a Title V septic system consisting of a 1250 gallon septic tank. distribution box and 2 precast leaching pits. The system was found to be in proper working condition at the time of inspection. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte& Ryan Devircent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 60 Chippingstone Road Property Address Brigitte & Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts N v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 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? ® El 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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•3/13 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 60 Chippingstone Road Property Address Brigitte & Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. C'Ityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Sve'r 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 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: original system installed 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron E 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 2.5 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: 1250 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. Cityrrown 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 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, tookmeasurements 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 should be cleaned soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet and outlet covers are on risers. 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•3/13 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 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,<y 60 Chippingstone Road Property Address Brigitte & Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 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 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.): H-20 Distribution box was in good condition, no rot, water level was even with outlet invert. Cover is on a riser. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•''t 60 Chippingstone Road Property Address Brigitte & Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 precast leaching pits. Pits were located and opened and found to have approx 4' of standing water with a stain line 1' higher. Covers are on risers. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I . Commonwealth of Massachusetts N . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte & Ryan Devincen Owner Owner's Name information is Marstons Mills Ma 02648 3/26/2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte&Ryan Devincent Owner Owner's Name information fired is every Marstons Mills re wired for eve Ma 02648 3/26/2018 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 0 i v ` Z A ► �g`b 3 3 124 '.j'? y 2 KY r�3417 � 33 (0s'l. A-� 5-Yr (i y &i � S 573 i3 75 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Chippingstone Road Property Address Brigitte & Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •�'< 60 Chippingstone Road Property Address Brigitte& Ryan Devincent Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/26/2018 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 < r _s v § :Al Ali $ y { y,,.�y, ��- .✓ 'ter vow AS RM9 � K yo f K q � Y 3 yg, f, � At• t d �✓ / 1 ✓' $ 00, I "WIN ww nt ti ,..� - S.�;_ "�;. '�Hj .?ram' `�3.'.. �'- '"�."'��:.: 44-.:�A• s - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F yA tl 9yw David B.Mason,RS,Certified Title V Inspector,508-833-217 fv1AP �•Z--� PARCEL, ' O I` ' TITLE 5 LOT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION qyz ®3 Property Address: 60 Chippingstone Road Marston Mills,MA ��I Owner's Name: Dale Partin RECEIVED Owner's Address: 60 Chippingstone Road Marstons Mills,MA Date of Inspection: October 13,2003 NOV. O 7 20 U Name of Inspector: (please print)David B.Mason TOWN OF BARNSTABLE HEALTH DEPT. Company Name:—N.A. Mailing Address:4 Glacier Path East Sandwich,MA 02537 Telephone Number:508-833-2177 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience'in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes X Conditionally Passes _ - Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatures Date: o/Jr-3/6 3 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: System as inspected appears to have operated based on occupancy level. Tank should be pumped as a matter of maintenance. The information as identified represents only the condition of the system on October 13,2003 at 9:30 AM. Increase in occupancy may result in hydraulic failure. A leaking toilet or plumbing fixture was evident based on running water. Page 2 of 11 ****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. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 60 Chippingstone Road Marstons Mills,MA Owner: Dale Partin Date of Inspection: October 13,2003 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: Septic Tank covers and d-box cover should be brought within 6 inches of grade. B. System Conditionally Passes: _X One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. _N_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: _Y_ 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 X distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) ND explain: N_ 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 f Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 Chippingstone Road Marstons Mills,MA Owner: Dale Partin Date of Inspection:October 13,2003 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 Chippingstone Road Marstons Mills,MA Owner:Dale Partin Date of Inspection: October 13,2003 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 _NA_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NA_ 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. —X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered Page 5 of 11 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 60 Chippingstone Road Marstons Mills,MA Owner: Dale Partin Date of Inspection: October 13,2003 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _X Were any of the system components pumped out in the previous two weeks? _X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site?(INCLUDING THE SAS) _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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:60 Chippingstone Road Marstons Mills,MA Owner: Dale Partin Date of Inspection: October 13,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):4_ Number of bedrooms(actual): 4 per Assessors Records DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents:_4 Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): Information Not Available Due to Well. Sump pump(yes or no):NO Last date of occupancy: (current) COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): 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 Source of information:Property 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:No pumping records on file. Per owner system has not been pumped for the last 4 years. 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): With pump chamber Approximate age of all components,date installed(if known)and source of information: approx. 15 years Page 7 of 11 Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 Chippingstone Road Marstons Mills,MA Owner:Dale Partin Date of Inspection: October 13,2003 BUILDING SEWER(locate on site plan) Depth below grade:Approx. 50 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_I00' Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. SEPTIC TANK:N.A.(locate on site plan) Depth below grade:48 Inches 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: Typical 1000 gal. Sludge depth:4 inches Distance from top of sludge to bottom of outlet tee or baffle:28inches Scum thickness: variable 0 inches to 6 inches Distance from top of scum to top of outlet tee or baffle:0 inches Distance from bottom of scum to bottom of outlet tee or baffle:Not applicable no scum at outlet tee How were dimensions determined:actual measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)inlet tee is PVC.Outlet tee is pvc and appears in good condition. No evidence of leakage. Structure of tank appears adequate.Effluent level with outlet tee. Septic Tank needs pumping- GREASE TRAP: N.A. 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.): f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 Chippingstone Road Marstons Mills,MA Owner:Dale Partin Date of Inspection: October 13,2003 TIGHT or HOLDING TANK:—N.A.—(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:_YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:Level with outlet pipe Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): There was evidence of solid carryover. D-box is structurally unsound. No evidence of leakage.Effluent level with outlet pipe. Cover should be brought to within 6 inches of grade. D-box is currently 58 inches below grade.New distribution box is required. PUMP CHAMBER:_(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.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 Chippingstone Road Marstons Mills,MA Owner: Dale Partin Date of Inspection: October 13,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number:2 Pits;6x6 foot depth leach pit with approx. 3 feet stone. leaching chambers,number: _leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etch Pit#1 Approx.48 inches of water in the bottom of the pit. No observed indication of staining in the pit. No indication of backup into the risers. Pit is approx 60 inches below grade. Pit is only an HI rate pit. No indication of ponding nor increase growth of vegetation. Riser and cover is 6 inches below grade.Pit#2;Approx.36 inches of water in the bottom of the pit. No observed indication of staining in the pit. No indication of backup into the risers. Pit is approx. 72 inches below grade. Pit is only H10 rated. No indication of ponding nor increase growth of vegetation. Riser and cover is 6 inches below grade. CESSPOOLS: NA (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: N.A._(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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 Chippingstone Road Marstons Mills,Ma Owner:Dale Partin Date of Inspection:October 13,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sk of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. all wells within 100 feet.Locate where public water supply enters the building. �,5 � (060 �L c L I Page 11. of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 Chipppingstone Road Marstons Mills,MA Owner: Dale Partin Date of Inspection: October 13,2003 SITE EXAM Slope Surface water Check cellar,{crawl space) Shallow wells Estimated depth to ground water_25_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 4 feet of bottom of leaching facility. Test holes in the area on file do not indicate ground water within 15 feet of grade. Barnstable Assessing Search Results Page 1 of 2 IKE --�- a �1E3 .... " .. f Al Home: Departments: Assessors Division: Property Assessment Search Results 60 CHOPI[NGSTON'"T IR®AD Owner: Property Sketch Legend PARTIN, DALE J Map/Parcel/Parcel Extension 027 /044/ Mailing Address MT PARTIN, DALE J 60 CHIPPINGSTONE RD 4 24 MARSTONS MILLS, MA. 02648 2004 Assessed Values: Appraised Value Assessed Value Building Value: $77,500 $77,500 Extra Features: $ 16,300 $ 16,300 Outbuildings: $0 $0 Land Value: $ 103,400 $ 103,400 Interactive Property Map: ap requires Plug in: Totals:$ 197,200 $ 197,200 1 have visited the maps before Show Me The Map April 2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: GAGNE,JOHN S&PATRICIA M 5/15/1995 C137030 $98,000 GILLMORE, EILEEN J TRS 11/15/1985 C104185 $90,000 MCCARTHY, ROBERT E C80400 $0 GAGNE, PATRICIA M 6/29/1999 C153760 $ 1 PARTIN, DALE J 10/27/2000 C159520 $ 170,000 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Tax information will be available on 10/15/03 Town Fire District Rates Other Rates 6.61 Barnstable 2.01 Land Bank 3%of To, C.O.M.M. 1.10 Cotuit 1.52 http://www.town.bamstable.ma.us/.../displayparce103.asp?mappar=027044&SearchBy--Addres 10/15/03 I r Barnstable Assessing Search Results Page 2 of 2 Hyannis 2.03 West Barnstable 1.36 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 1.04 Year Built 1979 Appraised Value$ 103,400 Living Area 864 Assessed Value $ 103,400 Replacement Cost$89,082 Depreciation 13 Building Value 77,500 Construction Details Style Raised Ranch Interior Floors Carpet Model Residential Interior Walls Drywall Grade Average Heat Fuel Gas Stories 1 Story Heat Type Hot Water Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip Bedrooms 4 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 2 Bathrooms Total Rooms 6 Rooms Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value BLA Bsmt Liv-Aver 748 $ 16,300 $ 16,300 Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area (Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/.../displayparce103.asp?mappar=027044&SearchBy=Addres 10/15/03 OCT-12-03 06 :48 PM BLAIRWELLBELOVED 7789530 P. 01 LOCATION 411is- SEW� Ap 1 VILLAC Act E ' RM1T p► E i INSTA ILER'S ' NAME i . AOORESS • UILDEit /a�l✓N�S OR owN[it e OAT E RMIT lSSUEa D 0 OATS COM►LIANCE ISSUED y 1 �� No. Fee-----, BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion for Vell Con$truct ion Vrrmit Application is hereby made fora pe .t to honstr ct_( Alter or Repair (i-ran individual Well at: Location.— Address Assessors Map and Parcel tut r. loa/Till -e- 0 A— Address /____ -------------- Installer Driller Address Type of Building Dwelling Other - Type of Building- No. of Persons------------- ______ Type of Well 91 — Capacity----- Purpose of Well--A—'s-!' Agreement: The undersigned agrees to install the aforidescribed 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 Certificate of Compliance has been issued by the Board of Health. Signed /A/ /X A n 'rh/0 �� � r - Application Approved By date" Application Disapproved for the following reasons: date Permit No. Issued a—ate BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered or Repaired by--- I ff Installer —------ at 66 tam (" ----- has been installed in accordance with the prolvisions,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 r- / _ _ DA No. Fee----- ------------- — __ BOARD OF HEALTH �-"----- TOWN OF BARKSTABLE Zippiicat ion,forVell Co0tructionpermit Y Application is hereby made for a pe it to Co1nstr c ),'Alter ( ), or Repair (fin individual Well at: G —�L�°c� — —fit —--- -- -- Location — Address r r Assessors Map and Parcel Owner p —Address -ZA J -IL!0/, 1 _{�? /�ox ?60_nn�i Installer.- Driller ------ Address Type of-Building Dwelling Other - Type of Building---- -_--___--- No. of Persons------------__—_--_ Type of Well `/ Capacity---------- Purpose of Wells=Ao 1 rt k wGl^' 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 Certificate of Compliance has been issued by the Board of Health. Signed u.., — t d Application Approved By ---__- 1, date Application Disapproved for the following reaso .11 —date---- Permit No. — Issued ate —_ BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (H by---- # i Installer 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-------- ----- —----__ BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con0ruct ion Permit No W -- Fee- ----_-_ Permission is hereby granted �� Sc� `` (/ -- -- -------------to Construct ( ), Alter ( ), or Repair ( L' an Individu j�Well jt 0 'Strelf. ------------------------- as shown on the ppl)ica n. for a Well struction Permit ��� �-sue' E�Z No.- - Dated- - - ---- -- - -------------- ------ DATE 6./Bo �of ealth • f 7 _ 8 T. OFT. (Minimum) °roi��s2 9 `— Outlet pipes from Dist.Box shal I be 18 Removable covers. �.�' level-for at least 2feet from box ' awayfrom _s stemma Ttght i6intS l2"max: i 1 -- V- .. liemovable:voac.covers ' W-Rore�hw 4Mof cover— 17 e _ 4 #. ;. Ret fade ttS.3.75,_max.cover. Liquid• Level. ,s=oo2' =o.a2' Proposed LOT 15 '2'llo roft/6 3✓8" �6, w o f ~' washod stone. . . .. 40,523 S.F. — Dist 6 Ft. SEPTIC TANK_ l3dx c` 1 ' ,�• r° =1250 GAL.— c4 co `� • ' , N. . °, C I . .. o o I .° o• 5 of coQ,rse sand used for I _ — GO . Co•, , . . . .' o I. �_T eff #ive depth— 2min. _ „ n . . ° a I ' Perc. rate. � Y Precast concrete a� a� a� a : Leaching Pit °� Go c c Eft. diameter ,. M 8I+ 401 N 2 r- 26. / i 14 Y SEWAOE DISPOSAL SYSTEM „ £ 24 Proposed241 TO SCALE 2 .of 3/4 to 11/2 washed stone 16 � blouse all around precast pit providin It ss. a 28' 86 48 ofr`effective diameter ofJ� se.o o. Test tii 100' :.uvalet}t io 440 gal.per day). hole iso' / 1250 gall vacant lot GENERAL NOTES eptic Tank 440 gal, per day, 1) No change to this system shall be made unless �: - Two 6diam.x depth Leac ing Pi with approved In writing by Philip D. Holmes. 2ft.of wo d tone I oround. square feet. Dist. 6ox T� square feet. 2) Subject to inspection during construction by \�,' • 2�•` T theBoord of Health and PHILIP D.HOL.MES . - Iss' to proposed well on lot 16 30' �>,t o 3 L12._gallons. per day. 3) Heavy construction equipment shaI I not travel over Disposal system during or after construction. 24 o'to proposed well lot 42 �r�e loading. area. , 4) Disposal system to be constructed in accordance B8 -; �� More than200 well-on lot4z 20 N.E.TBT Co.Easement with Title 5 of the State Environmental Code. 25.00 j 5) Flood Plain Haizard Zone C 87.1 — —CH 1 PPINGSTONE —�ri�ote 4d Wide 85 7 RD. 40' NOTE : 6) Zoning District R D — 2 I) A COPY OF THESE PLANS MUST BE KEPT ON THE SITE DURING CONSTRUCTION. �% n rnov ne Tuccc 01 A11Q RA1 ICT O='m inktteLlCn _m LOCATION` /� SEWAGE P RMIT N0. /V @, VILLAGE M INSTA.LLER'S NAMEI i ADDRESS 'MAN t-laz CIA 'g-m /✓ rS d U I L 0 E R OR OWNER Ile Al i DATE PERMIT ISSUED LZ OMPLIANCE ISSUED DAT E C I i I v N6 1 '8 1 Massachusetts Department of Environmental Management Office of Water Resources 1 0 4 2 1 7 TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION [GPS (OPTIONAL) LATITUDE = �� -LONGITUDE r Address at Well Location: 60 Property Owner: MI ' ` /*Oft ' _ Subdivision Name: ) Mailing Address: City/TOWn: u $t s � Ma 0262 City/Town: � OJGY,j Assessors-Map �Ja-I Assessors Lot#: 0 NOTE: Assessors Map and Lot# mandatory if no street address available Board of Health permit obtained: Yes 2' Not Required ❑ Permit Number D to a Issued 2. WORK PERFORMED 3, PROPOSED USE�:z T; w 4.DRILLING METHOD ❑ New Well ❑ Abandon C]`Domestic ❑ Irrigation ❑ Cable D_Auger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer Direct Push EZ-Re lace ElOther ElIndustrial El Other ElMud Rota 'D Other 5. WELL LOG oC Unconsolidated Consolidated 6. SITE SKETCH (use permanent landmarks with distances) .Penneabi14 � -0 _0 From (ft) To (ft) High Low 0 m Other Rock Type c� err✓l A . 7.WELL CONSTRUCTION 8. CASING f•, 'Total Depth Drilled 60 From (ft) To (ft) Casing Type,and Material Size O.D. (in) Well Seal Type. ' Date.Drillin Co plete O s/ 9. SCREEN A From (ft) To (ft) Slot Size Screen.Type and Material Screen Diameter SG 1O..FILTER PACK/GROUT/ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION J Developed? ❑ Yes ❑ No From (ft) To (ft) Material Description,-,_), Purpose Fracture Enhancement? ❑ Yes ❑ No Method_ Disinfected? ❑ Yes ❑ No 12. WELL TEST DATA(PRODUCTION WELLS) 13. STATIC WATER LEVEL(ALL WELLS), Yield_' Time Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM) _ (ti7s°&min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) `/Alb y 14. PERMANENT PUMP (IF AVAILABLE) 15.NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description foLS-Og 'P Horsepower 16-, e Pump Intake Depth .S� (ft) Nominal Pump Capacity (gpm) 16. COMMENTS � 1 17.WELL DRILLER'S STATEMENT, This well was drilled and/or abandoned under my supervision, according to applicable rules and regulations, and this report is complete and correct to the best of.my knowledge. Driller: Supervising Driller_Signature: Registration #J 1 21 I I Firm: ` Date: S��/6a Ri Permit#: I I 19 II NOTE: Well Completion Reports must be filed by the registered well:driller. within.,30 days of well completion. BOARD OF HEALTH COPY.:" THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ------. .- ............._0F.......................................--.............................................. 'Appliration for UhipsFal Workii Tuntitrurtion famit t� 6 Application is hereby made for a Permit to Construct (Yfor Repair ( ) an Individual Sewage Disposal System at: ........M.f.ALT..Q.A1.., ....144 [,L4---••------------------------ --L C�Z_..... Loc ti ,,nddres or Lot No. ................................... .........--� Owner Addre_s.s. _ . Q .Q. ...��A✓.�� �.!/vd J.AJ._1,.......................... ..._.... .......� � . 41 ) � I ......... Installer Address .�. Q Type of Building Size Lot_.__-y. J_. .-Sq. fee Dwelling—No. of Bedrooms................... Expansion Attic' Garbage Grinder-{ aOther—Type of Building ............................ No. of persons-__-_____-_____-_--..-__-- Showers ( ) — Cafeteria ( ) Q' Other_fix ures .--•-••-•--••......•--••--•---•- ,.j W Design Flow_.......__ ..................•......._gallons per person per day. Total daily flo,,y__._._.7_y.Q.......................gallons. WSeptic Tank—Liquid cap,,,,a//city. gallons Length_,.-.�a_.... Width.''_-_.!0 Diameter---.—_-__. Depth_-`1�`_-``--�._2V IAI. x Disposal Trench—No. ..�Y-A....... Width_.._..------------- Total Length............ Total leaching area....................sq. ft. r �1 Seepage Pit No...... Diameter....../_6_._..... Depth below inlet................. Total leaching area....'Y 7. ._sq. ft. Z Other Distribution box ( 0 Dosing tank ( ) '-' Percolation Test Results Performed by...l'/'ju.(-P....o......#0.1-&1 ............... Date..15Px-�-7-_JY78 Test Pit No. 1-----,o;.------minutes per inch Depth of Test Pit--------/._��__----- Depth to ground water_____l�__��..._._._. (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water......................... r4 ------ -------------------------- -------•----•--•-------------------•--•--••--•--•--•••---... O Description of Soil_.__-L17fa..M.�.In/.�QeS'01.�---1V��.t'��.--- _QW/�_..Tv � L.,6,47.#......T.�� ..... x �5 __.Fh.ar�.......�s,.._:.�`>,../ �Q�'�ter �� - w---d � "� /��/ „� �y A` Yl f ht� � ----•----•----------- --- (l_h- .... 6�K { ••---•V- t�, � C U Nature of Repairs or Alterations—AnSwer when applicable.___________________________________________________•._.______.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT :;,:, p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig ---•--------------------------------------------•-------------------------•-•-----•--- ------------------------------- Date Application Approved By....... y �G% ........_... `/-.7 --------•-- ��� Date Application Disapproved for the following reasons:--- •-------------------------------•------------...----------•-------•-------------------------------.......... .......................................-•------•--•---•---------•--------•------•---........---------•----•--•••------•--------._...---•---•-------••-••-••--•-----•--••---•••-----•--•--••---...._.... Date PermitNo......................................................... Issued...Z - --•• -�-.7................... Date rz3�.`� 04 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 60 CHIPPING STONE RD. MARSTONS MILLS LOT 15 Name of Owner PATRICIA GAGNE Address of Owner: SAME Date of inspection:. 4/6/99 Name of Inspector:'(Ple se Print)JOHN GRACI I am a DEP appro�red system inspector pursuant to Secdon 15.340 of Title 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02536 Telephone Number: (608)664-6813 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: t X Passes The inpection is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:4/7/99 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. I revised 9098 Page 1 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:416/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any Information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: na 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. na The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is Imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. na Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced na The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass Inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:4/6199 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER D& revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:4/6/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n&. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the Invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must Indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 912198 Page 4 of 11 SUB SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:4/6/99 Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9098 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 15 Owner: PATRICIA GAGNE Date of Inspection:4/6/99 R SID NTIA ; FLOW CONDITIONS Design flow:_440 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: An Number of current residents:$ Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): No If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n(a Sump Pump(yes or no): NQ Last date of occupancy: n& COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:n(a Last date of occupancy: n(a OTHER: (Describe) n& Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: n& System pumped as part of inspection:(yes or no):NQ If yes,volume pumped ala- gallons Reason for pumping: n(a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM WAS INSTALLED IN 1979 PERMIT#7 464 Sewage odors detected when arriving at the site:(yes or no): NQ rn.icnr!ninmo SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION I N FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:4/6199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n& Dimensions: Wa Capacity: n(a gallons Design flow: n[a gallons/day Alarm present: MQ Alarm level:ilta- Alarm in working order:Yes_No—: MQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) IVA DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet Invert:n& Comments: (note,if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n& PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): MQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:416199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: 2-1000 GALLON LEACH PITS leaching chambers,number: J7(A leaching galleries,number: _n[A leaching trenches,number,length: n1A leaching fields,number,dimensions: n& overflow cesspool,number: WA Alternative system: n& Name of Technology: jVa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,ONE PIT HAD 4'OF WATER-AND ONE PIT HAD 1 OF WATER IN lI. CESSPOOLS: _ (locate on site plan) Number and configuration: n(a Depth-top of liquid to inlet invert: n& Depth of solids layer: n& - Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n/A Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) D& PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) WA revised 9098 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:4/6/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a d CA 44 �8e Q 46AC a�� Ap 5� AC sa revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 CHIPPING STONE RD.MARSTONS MILLS LOT 16 Owner: PATRICIA GAGNE Date of Inspection:4/6/99 NRCS Report name: n/a Soil Type: n& Typical depth to groundwater: n(a USGS Date website visited: n& Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps - Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2/98 Page 11 of 11 No. rp� 3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Zigponl by.5tem Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System individual Components Location Address or Lot No. p / /+'� N� Owner's Name,Address and Tel.No. �'�*7 �j.42S'To�s�/lei ✓ O a 1c�' Assessor's Map/Parcel "� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil, j Nature of Repairs or Alterations(Answer when applicabk, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is y thi . o lth. Signe Date Application Approved by Date D O 3 Application Disapproved for the following reasons Permit No. 07-00 3 —50 3 Date Issued lo -5 U "- Y - - .,. ... _✓.�,e�nr..w-4M«-L. �.i;r... v"(:I-�.v.M a rr - _ ,� ,---.-w----_ __ _ .+ � i, sr — V. No. Fee 5 Entered m co uter. THE COMMONWEALTH mP 0 EALTH Of MASSACHUSETTS 4 Yes \ PUBLIC HEALTH DIVISION -TOWN F BARNSTABLE,0 0 MASSACHUSETTS \ ZIpprication for Ziopool *pe;tem Construction Permit Application for a Permit to Construct.( )Repair( )Upgrade( )Abandon( ) 0 Complete System >Qividual Components 1 Location Address or Lot iVo.!�p N' .�foN�` Owner's Name,Address and Tel:No. ti Y rro,­�s .t �'�T Assessoris Mai)/Parcel Install�Name,Address,and Tel.No. Designer's Name,Address and Tel.No. - Type of Building: , Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ff No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ` Size of Septic Tank Type of S.A.S. ,s Description of Soil �Y y_ i Nature of Repairs or Alterations(Answer when applicab Cc'400�.64G jy e"711 j Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu y thi • arA of Health. Signed ' Date �O" Application Approved by Date /0 -g O 3 Application Disapproved for the following reasons Permit No. OLSO j `50 3 Date Issued /0 /� U THE COMMONWEALTH OF MASSACHUSETTS C BARNSTABLE, MASSACHUSETTS _ Certificate of Compliance to . THIS IS TO CERTIFY, that the Oh site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by , at 1D G h 1 D 1 a.S4VYU_ fv�'1 S IS has been constructed ' accordance with the provisions o Title 5 and the for Disposal System Construction Permit No. 2 00-3-.S03 dated /0 Installer Designer f The issuance of this e t shall not be construed as a guarantee that the syste e w"a iv ik ` ° k .P ' jed Date C� d3 Inspector / 7� •�. -. . . � --- ———————— ———————---——————No. Fee 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS migogar *pgtem Construction Permit �Zo?< Permission is hereby granted to Construct( )Repair )Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructionpiust be completed within three years of the date o himpermit. Date:_ 3 Approved by i , Irby p �- IOCATION ��` / SEWAGE Y RMlT NO p1 ©!V VILLAGE �IQAsT W:s A'? /ls INSTALLER'S NAME i ADDRESS 2AN1,iaZ (:QAQ-A 1 .J& /�, ',5 To l e ) A IVA" `5 d U I L D E R OR OWNER C--IleAl L�'L Ij DATE PERMIT ISSUED 0 L�Z DAT E CORIPLIANCE ISSUED B - B c o C S s awe ;v�corr2c� A - -bvx q7� B D-boy- �D�o IO�t'1�p3 r` A Fmc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .:.p ........................OF...................................... .............................................. s, , ppftratilaai for Dhipoii al Works Towitrurtiou Famit Application is hereby made for a Permit to Construct (00 ) or Repair ( ) an Individual Sewage Disposal System at: �/•• Locati -Address ^/ or Ldt No. • ..... .4e. IK !1C ................................... ...........i4� l r!✓G.c�i�+�- i� .-.. .. .R.;......--.............. Owner Address J Installer `T Address Type of Building Size Lot...... _6::;23 . .-S Dwelling—No. of Bedrooms__________________ Expansion Attic"t"-- Garb4e Grinder 24W— aOther—Type of Building .....................:_.:___ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures - ='- ........................................ d - W Design Flow_-______..16.�_____________________ _gallons per person per day. Total dpily flgiv........ f�........................gallons. W Septic Tank—Liquid ca t� 0_gallons Leng4h<&_ _f2___._ Widths 7._(2 Diameter---- Depth____a__�1�A Disposal Trench—'�To._. ...�______. Width_____ _ Total Length __ Total leaching area_______________ ___s ft. x p . g g q Seepage Pit No..... - -- Diameter____.l0........ Depth below inlet..... Total leaching area._ ....sq. ft. z Other Distribution box (�) Dosingtank ( ) ►� I J P- �,....�O.t s---------------- Date_---- T, o? j`�76' Percolation Test Result, Performed by._ ___. ._ __ __ _ _ /�....__.O_� -_-_-.. Test Pit No. 1..... .........minutes per inch Depth of Test Pit......./........... Depth to ground water_________ ._............ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O So ---VTH...---�� .. -- Descriptio of � � " � w - . ........... A/t­ *4tw W - -------------- ----------------------- - ---------- ------- UNature of Repairs or Alterat ions—Answer when applicable. - ,:- ---- u Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal"System in accordance with the provisions of TITLs 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig ed............. ----- __....-•-•--------------------------•---___--•--------• ---------------- _-•-••-••--•-•-- Date Application Approved By....... r` Y .....- /. Date r Application Disapproved for the following'reasons:- i......................................................................................................... ---------------------------------•--..._..---------•----------•-----------•---.----...........__...--•--•••-----•--•--•--•-•-----•-------------•••------------•••-•----••--•-••-----•-----•-------•.--- \ Date PermitNo......................................................... Issued•....................................................... Date 10-1w THE COMM #, L�TH OF MASSACHUSETTS BOARD OF HEALTH ijQ / /J i Trrtifirab laf Toutph aurr THI IS TO C(`��jRTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) * by x ..................... ,, A u Inst ler _47 ...(1#1 has been installed in accordance,with the provisions of TI ' ` fT e State Sanitary C die �s ddes ribed in the application for Disposal Works Construction Permit No. .............................. dated-:::�. --------__/ _ ____________________ 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 y -70 ..... ... OF..... '..... ......No.............. ...... FEE........................ i tea �a� rrrk r Ilan am r Permission ereb gra ed_____________ V __•_. / 7 __•______________'...............................................4., ............. to Con c ( ' ) r p ( ) an ua1, ewa is os ystem l at N .... - t ��/{n� .-f�g �' J"� /••--' _ ..--.,....._ ,.Y. ` st eet�/ y, 7L as shown:on the application for Disposal Works Construction P t N _____ ___ _____ Dated.___ ..�_._._.__...�____._..._.... � �b U4A '................... -• Board of Health , / - DATE ( � ------ ---------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 1 7 8 T 20FT. (Minimum) _Outlet pipes from Dist.SO) shol I be 18 oro���`'/4, 9 Removable covers. ,f - level.fdr at least 2feet f m box or . Top fnd'n 10 FT. (Minimum) assigned a Finish rode-min.slope of 2° away fromj s stern , • bntS 12ma ,t Removable'c 6nc.covers ' _ �,d 4 Q, Not mode thou 4 of cover- 17 ; T!C�Q A Aq:L�- Wl7w g Refode to 3.75 max.cover. /1FT5' - t, LOT 15 , . Liquid Level 'S=0A2' � -0.02' . :~, i �� � Proposed 2lay�rofl/6-3/8 ls - s= o.02 I washed stone. s l5' l 40,523 t S.F. 6 Ft. o a c; —SEPTIC TANK_ BOX Ili• ' : ,^ �� • • o a M a —1250 GAL.- cv co 00 M — — . rrj N c�i a . .. e o o --o• 5 of coo rse sand used for " w -- ao allo °D , ;°D • • • • o a °_I-�, effractive depth- 2min. u — _ u O n II ' w _ . .• . o , ' �nt- perc. rate. L ' W W W c � s . • . o o ,� 1 - O� O W i +. Precast concrete c �, Leaching Pit ao E c c c c 6 ft. diameter Q1 �' M 48,t i-5 f 8 7.5 4 SECTION OF SANITARY SEWAGE DISPOSAL SYSTA 2 2 f Propo36,se 0 14 , 2'of 3/4"to I I/2'washed stone 16 �� 2 j House 'F NOT TO SCAL E — 88. 8 28' �s all around precast pit providing 48'# ' oh-effective diameter of 10'. 88.0 N; lop' DESIG CRITERIA n Test `ti°°' Number of bedrooms equivalent to 440 gal.per day). h°ie& 150' O 1250 gal! vacant lot Garbage disposal unit None GENERAL NOTES , eptic Tank 1) No chap a to this system shall be made unless Leaching area-capacity re fired 440 gal, per day, g Y °' Two 6diam.x 'depth Leac ing Pit with approved in writing by Philip D. Holmes. Dist. Box`—T2ft.of washed tone I around. N" Side Area proposed 14 square feet. 2) Subject to inspection during construction by Bottom Area propose •157 square feet. the Board of Health and PHILIP D.HOLMES . —r 185' to proposed well on lot 16 30' u�0 o Proposed Leaching Capacity�4.2..—galIons per day. 3) Heavy construction equipment shaI I not travel Water supply private well over disposal system during or after construction. serve o 240 to proposed well lot 42 area. Precast concrete units, H—10 loading. r 20 More than200 well on 1ot47. 20 N.E.TaT Co.Eosement SOIL . LOG 4) Disposal system to be constructed in accordance B8 with Title 5 of the State Environmental Code. - N' I � 87.1 —.., 125.00 \ _ 85,7 Surface 5) Flood Plain Hazard Zone C CiH I PPINGSTONE�rivate—4o wideRD. 40 f El v.= -87 I • NOTE \' loam 6) Zoning District R D — 2 I) A COPY OF'-THESE PLANS MUST BE KEPTON THE SITE DURING CONSTRUCTION. r 2) A COPY OF THESE PLANS MUST BE FURNISHED TO CONTRACTOR CONSTRUCTING SEWAGE DISPOSAL SYSTEM. r" subsoi 1 3) BEFORE BACKFILLING THE SYSTEM,THE CONTRACTOR SHALL NOTIFY PHILIP D. HOLMES AND THE BOARD -..- r 7)Bench Mark Spike in.NETBT sole#462 CHIPPINGSTONE: OF HEALTH AGENT TO INSPECT THE SYSTEM AS CONSTRUCTED. clay J RD. Elev.=88.05 appmx.seo level datum. PLOT. PLAN REVISED MARCH 28, 1979 P� Si.I OF PROPOSED SEWAGE DISPOSAL SYSTEM SOIL TEST REFERENC_': FOR JOSEPH C. POLCARO _ Date of soil test SEPT 27, 1978 Land Court Flan 34846Bsheet 2 IN ;rt r coarse Test taken by PHILIP D. HOLMES LOT 15 MARSTONS MILLS BARNSTABLE., MASS. � sand Results witnessed b Paul Murray, aul Gardner SCALE:�=4Q DATE: Ak ti Y -�� DRAWN BY R•S J• CHECKED BY PD . „ '; 75.1 Percolation rate-_2minutes per inch. PHILIP D. HOLM - CIVIL ENGINEER LAND SURVEYOR. No ground water encountered. 301 MAIN ST. FAL OUTH MASS. N 78298 DWG-NQ A 69 1 . SHEET I 10'— 0" AI I outlet pipes from the d)stribution box shal I Outlet _j be set level.for at least 2 from the box. Knockout j Al I access Manhole covers for Septic Tank M ' INLET —�- OUTLET —►- = Distribution � and/or Leaching.Pits set - • o more than 12 below finished grocte,shdfl-be _ -� INLET \ OUTLET _t raised to within 12aof finished grade.to Outlet Metal framg &cover or.:cct to co; er Cnockouts' over= ms' where requ, t d;l°+ ,1.R �. . r . VB crete block masonry 21-0" 1 -2$T f EL I,t i:FQ.Rt E.t�-PRE"CAS.T CONCRETE _ or ick.mosonry Removable covers 311'f h` _ /:Concrete cover '<< " -Conk. .cdver. t , } jj •' 211 min.'deoronce Fequired. n eINLET' OUTLET -2"min.inlet to octet 6"n. 13 INLET—a- / � ' '0�e x ` OUT LET —�- f' oCkOutS 2. <; OUTLET--.. >t 10'm1n. Liquid level 14" � f min. -' 'R'�.+h i F"i + 11 a ,r 6;min. 6-0 -0 _tf 6 In. j 1 , M � TYPICAL DISTRIBUTION BOX SCALE, -1 11 - II—O'" r i4 —1LT}_%Z ° " •1- + •. - � Z +z'j, a�Y � -�i t� �•.� i�� • `,i,. >, 10-0 5 -0 ty , TYPI CAS 1250 GALLON SEPTIC TANK t .�' •i• i� 4' a.. � � ff Est{. ,. • jx LOT 15 CHIP RD. m r „ ; REVISED MARCH 28 1979 PLOT PLAN --- DETAIL SHEEP OF PROPOSEDSEWAIGE CtSPOSAL SYSTEM . FOR JOSEPH C. POLCARO MARSTONs MILLS BARNSTABLE MASS ��F J:t 3 zw i 1 i t Nl vy s t: 1 fir.. t; �, �. D SCALE DACHEp<ED 8Y 19,127A �.,. R_&J. E 4 't'f• A � 9 - 'l•�iy'Y ;y }5. t r, � - -.PHILIP D. HOLMES. ` CIVIL ENGINEER LAND ,BURN Yt3f`Z ` �4, MAIN 7' FALMOUTH ASS. 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