Loading...
HomeMy WebLinkAbout0112 CHIPPINGSTONE ROAD - Health c ippingstone load ,:rvi:arsti�n:= Mills 028-112 s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information _ filling out forms on the computer, 4 �r use only the tab tr key to move your 1. Inspector: D �- cursor-do not ; Ricky L. Wright use the return Name of Inspector L I key. B & B Excavation, Inc. r� Company Name By 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/10/10 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. l �� t5ins•09/08 Title 5 Official Inspection Form:Subsu ce Sewage Dis"osal System•Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 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 15.303 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•09/08 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 °M 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 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 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 '/day flow t5ins•09/08 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 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 � Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 112 ChiPP 9 in stone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. CityTTown 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 ears usage d n/a 9 ( Y 9 (gP ))� Detail: 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. City/Town 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 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: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' 5" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good condition - no sign of leakage Septic Tank (locate on site plan): Depth below grade: 1 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: 56"X 66"X 10'6" Sludge depth: 6" t5ins•09/08 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 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 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 31" Scum thickness 6" 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 12" How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound - no sign of leakage- pumping is recommended 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. Cityrrown 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.): At time of inspection d-box appears to be in good condition. No sign of solids carryover or leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) ❑ 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.): At time of inspection leaching was in good condition. No damp soils or pondin 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 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 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building._Oheck one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C`hlpprnclsfr�eOCiCJ'. 13 A Al 15' 9 '' A Z 2S S � A3 ; 34' S A4 = 38' 5 AS 39' 9 Lai 131 = 25 '-B2 . 2 5 ` q '' S '33 - 321 y By = y 2. ' BS 39 ' 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 s= • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. Cityfrown 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: > 15'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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/06 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 112 Chippingstone Road Property Address Jonathan & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 9/9/10 page. City(rown 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 (ZOR�2T T. Sor,_MLlCi MOLLY C. SOMMELLCD NOW, tHEREFORE, 2OP-EIZT v . NICnTE2A does hereby place the (owner's name) following restric ion on his above-referenced land in accordance with his i a r�eem'iant.. TQwi3-&Barmtable- rd--8��, whieh trietion run with, the land and be binding upon all.successors in title: i � _ i112 CN kFV1 e.ir�s-rOKIE eOA.o , may have constructed (address) upon the lot a ouse containing no more than-"+QEE (3) bedrooms. P-OPA-l2tT.4o¢f3C-ul_o I moLil C.Soe6a-Lo agrees that this shall be permanent deed ebeet2T T NlEO A(o ers name) restriction affecting MgVtzMocated on Ill-CAtffiko6rot ltz ')PIMA, and being shown op the plan recorded in Plan Book 24a3i' , Paged &S Or on Land Court Plan , i For title of erY see the following deed: Book 14831 , Page 68 Or Land Court Certificate of Title Number Executed as a sealed instrument I�iT� day of4errEMf5F_V , 2010 _T- Owners igna ure t A 1�14 Owner's aig6a ure M 40neft signs ur ` COMMONWEALTH OF MASSACHUSETTS MI6 ss r , 20t1 Then erson Ily appeared the above-named T a,�8�ilr Inod L4_ for Lo V A)II I known to me to be the person who executed the foregoing instrument and acknoilviedged the same to a free act and deed before me Notary My commission expires: (date) d��"� BARNSTABLE REGISTRY OF DEEDS g, Bk 25320 P:9156 13813 03-16-201 1 DEED RESTRICTION WHEREAS, ¢or�`2r-r.-6oQrZEiuo) MOLLY C.soQlEu�, Qo CLr v. NICOfTEe4 (owners name) r i 2 e>� Pik YzSTb►�1E �� MA[2� 1, .!'S MILLS 1 SA¢►.YT'W► -L(E MU►.I-QY MA (address) is the owner of P2vrfEv_z-v located (address) at i 12 Jai r"K1e L<.rDt lE W64---) j AA&24_Tom► , MILLS fA&¢IJSTAR; c9di l 1 MA (hereinafter referred to as 111 COI PP1 (Z0A� and being shown on a plan entitled "Subdivision of Land in MI 2�i1<JI[A�16 MILD MA, Property of e0GEeT T. -5ou-iE -o ,NWLLY c `9Q L.W) l IR4C3MT Y. N I co TE"lZA et al, Aio r�ZOPE2'r�C duly recorded in Barnstable County Re gistry of f Deeds in Plan Book 2 831 Page '�;8 ; Or on Lind Court Plan Nu mber. `0e;C- 2r T. -_:.oO9ELLo, MOLLY c.. S,026E1i.0 WHEREAS, Qoer 'v. nii coTAt kas the owner of said I t has (owners name) agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-con�tition to obtaining a disposal works construction permit in complia ce with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Bamstable Board of Health, as a pre-condition t granting a disposal works construction permit for a septic tics stem in compliance P p Y with 31 C CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and auth rizing,. the issuance of a building permit for the construction La Y e g p uction of a single family h �� v f this pro erty, is requiring that the agreement for the restriction on the nu ber of... �►- bed in any house constructed on the lot be put on record with the : Barnstable County Registry of Deeds by recording this document, Altfl�U� ZeI DO SG t (o(Z I v}L SL LOT B-2 P `t: os�m. 5� LOT B-3 AREA= 43,182j- sq/ft i r° 26 5 g 5���6510 AS LOT 44 s 16 53 3 cp �39 i d p 2 0. FO UNDA TION 6 137 5' Nw 3 cry AS LOT 45 CR V O h6 AS LOT 46 U AS LOT 47 W1JfW0Z1Yd 1) -7-00 1?qcc� FLOOD ZONE "c"_ FO UND_A TION CEI?TIFICA TION RES ZONE.- I RF" TO WN.MARSTONS MILLS SCALE-]"=50' PL.REF'549124 .ELEV N/A I CERTIFY THAT THE ABOVE YANAEE SURVEY CONSULTANTS FOUNDATION IS LOCATED ON �' ~ P. 0, BOX 265 THE GROUND AS SHOWN, AND MEN THIEW: UNIT 1, 40B INDUSTRY ROAD IT S POSITION —DO�'�5__ No: 32 f CONFORM TO THE ZONING jA YY MARSTONS MILLS MASS. 02648 . 4 5'mx\ ' TEL 428—0055 SETBA CA' REQUIREMENTS OF �k •<�, c 'if BAR TABLE �'cu �:lr FAX 420-5553 q ----- "'k=- 3 3 -- �¢ PAUL A JdERITHEW 4 t7 7 DATE' f2 NUMBED 00 JOB 52511FND I own of Barnsl, ........9�67 3 Department of health,Safely,all ruivirol,III c III aI Services �n+E Public Health Division male 367 Main Sitect,I lyannis MA 02601 IIAn11BTAnr.r; I NIA9s p 1639. 6" cF Dale Scheduled 12—" �0 ! It cc Pd. o J^ Soil Suitabilit>) Assessment, v Selvage Disposal Performed Ily: Wilncstcd Ily: -Danjy ��t sVC— 1 ►l„�tY�nn. � LOCATION & GENERAL INIFORIYIATION Location Address Owner's Nanae $Zo..i 1p Address Assessor's t1ap/1'arccl:z8 Engineer's Nanic,( ��GL v NEW CONSTR1lCTION di REPAIR Telephone Land Use — �— Slopes("o) Surface Stones. Distances Ifom: Olicii\\tiller Bodyy�h\`11,1�{, 11 Possible'Wet Area�_R Drinking Water\Veil 60 fl Drajnagi:Way r v —11 Ihopcity Line Il Other R S KETCI I: (Slrccl nanic,dimensions of lot,cxael lucaliuns of lest holes& icrc tests,locale wcllmids in ttoximil to hole I I Y s) I C)G I I a 100, Pb Is6 - � � 1'arcn(material(geologic) ��ojjlylzvy Depth to Ilediock (A Depth to Gioundwalcr: Standing Water in I lole: in a)! Q, Weeping from Pit Fnce I-slinmicd Seasonal I ligh Groundwalcr 1)ETCRMINATION VI OR.SEASONAL III GI1.;WA`I'EPIt.1'AI3LE Method Used: Depth Observed standing in oils.bole: in. Depth to soil mottles: Ucp1h to weeping from side of obs.hole: in. Giomidwaler Adjustment Il. Index Weil H _ .. RnadinR Date: _ _ Index\Veil level _ Ad.i.factor..-- Ad.i.Groundwalcr Level PIItCOL,A'I'dON'I'1,.5'I' finite 1 Io Time it�Qb Observation t ^ I lole It d• time at 9" d, Depth of Pere Time at 6" Start Vre-soak Tinic n ( JD Time(9"-6") _ End Pre-soak l r 16 Ratc Min./Inch c� Site Snjlabilily Assessment: Site Passed Site fnilcd: Additional Tesling Needed(YIN) Original: Public Ilcahh Division Observaltoo hole Daln To Ile Completed on luck j Copy: Applicant !tole It lkpill Poill Soil ifOli7.011 soil Texiloc S.oil Color soil CMlier Surface(it).) (USDA) (Mollsell) Muldilig (Silucluic,Stolics,linuldcrcs. ............. jok q�p.np II)EEP OBS1.00"ATION 11OLIP, LOG Hole 11 DC11111 I'lom 'Soil I folIzoll SoilTexhou Soil Color soil 011icr surface(in.) (I IS DA) (N fit I Ise 11) MOIllilig (SMIClUrC,SlolICS,110ol(IM5. Cp -vv DEEP OBSE,10"ATION 11OLE, LOG hole 11 Depth fiolo soil I lot i7,oll soil I'c.xliitc Soil Color Soil Ulhcr Slit (ill.) (USDA) (Nionscil) Molding (Sillicluic,Sloncs,lloilldcles. DEW'P 011SEAVATION 11OIX, LOG I tole 11 Depill from soil I lorizoll soilTexhlic Soil Color soil Other snrhrcc(in.) (USDA) Moilliog (Siloclurc,Stories, holilducs. 4;. Above 500 year flood boundary No Ycs Within 500 Year boundary No Yes Willi,in 100 year flood boundary No Yes Pc.wtb Does ;I( least Four feet of naturally occurring pervious malel ial exist ill all areas obscl Vcd fill ougholit file -11-ca proposed for file soil absorption system? If nol, what is file depth of 11,11111-ally occurring pervious material? 1 certify Illat oil yh (dale) I have passed file Soil ewilumor examinationexaminationapproval by file I kpa I I I I I c I It of F I IV i I o n I I I c I I u-I I Pro I ccliol I and t I I a I I I I c above analysis was I ict-Fornic d by It I ccoosis I c I I I \\,i(I I the re(joircd (raining, expertise Mid cxPcI'iclIcc described in 310 CMR 15.017. sigoahlre Dale TOWN OF BARNSTABLE LOCATION a SEW ) ! 3 VILLAGE- alr ASSES OR'Sh1AP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) - ®O (size) �00�­ f NO. OF BEDROOMS AT TTT T1vu /'1D r1\lIAiRD PERMITDATE: OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Priva te Water Supply Well and Leaching Facility If an w PP Y $ ty ( y ells east on site or within 200.feet of leaching facility) Feet Edge:of Wetland.and Leaching.Facility(If any wetlands exist �3 within 300 feet of leaching facility) Feet Furnished by 1 , It I : I 7 c - 0 f� i A(1 C i TOWN OF BARNSTABLE L:cCATION �� C � � (� N �D SEWAGE# 112 f� VIL1AGEMA4,5 PAT NI_ ( ASSESSOR'S MAP&PARCEL NAME&PHONE NO: SEPTIC TANK CAPACITY IS O. Can 11,0/US LEACHING FACILITY.(type)( sbo NO.OF BEDROOMS OWNER qAJ 1 �e9�t)r �l rL S T DATE: °L o COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundw_a�ter Table to the Bottom of Leaching Facility 45 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) " 4Feet FURNISHED BY rA\,(—E �USy!3 ,. a, Chipping one Rd i W ' A Front 112 Chipping Stone Rd m Marstons Mills, MA 02648 .i a 3 Bedroom House B Al Q e 1 Q 1500 Gallon Septic Tank, A2 p a� - A 1-15'9' B 1-25' 3_ 2-23.5' 2-- D=Box 3-34.5',, 3-38' 4-38.5' 4-42' ` 5-39.8' 5-39' O O ' 5 4 (2) 500 Gallon Leach Chambers J I l TOWN OF BARNST LE . . I 1. LOCATION a' ►�sL SEWAGE # VILLAGE 1pra ASSESSORS ASSESSORSAAAP & LOT® INSTALLER'S NAME&PHONE NO. H -- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ®Q (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 Fumished by Hur ° ` A p j` t—ro✓fi g^ C= i h5? No. r v l - FEE.. COMMONWEALTH OF MASSAC14USETTS Board of Health �.��I�IS�'a.�0�`� MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for Perm't to Construct�Repair( ) Upgrade( ) Abandon( ) - Wklt'oomplete System ❑Individual Components Location C' H )P 12)V 6-SIONE QO Y4 Owner's Name Map/Parcel# A 7 Address Lot# — Telephone# Installer's Name Designer's Name /q)ukee Su Ri/E Co-1 S o(J-9 Ain Address Address /-/O)� ,L-P-Ou ITR,/ RO A'!� Telephone# Telephone# L f Ae— oO S S Type of Building Lot Size 7 11 18 a sq.ft. Dwelling-No.of Bedrooms 3 Garbage grindeyVO Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 3 3® gpd Calculated design flow 3�o Design flow provided gpd Plan: Date 10 — A3--O O Number of sheets Revision Date Title S r`�l' }' S f'wCi` S L.A P Description of Soil(s) Se-e LA P Soil Evaluator Form No.-#- (;i'3 3 Name of Soil EvaluatoMt tz y 4c),J9 G fVDate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Thgaees ed agr t goecribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur to t o a . eeration until a Certificate of Comp'an�� been issued by the Board of Health. Sig Date 0� FEE No f .+' -+'+i1M�l�. `�'• ..mom ` OF S 1� `ACHUSEYYS Board of Health, ����S�a �- ,MA. r APPLICATION FOP, ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for /hermit to Construc*( epair( ) Upgrade( ) Abandon( - ®'Complete System ❑Individual Components / r m Location C° }q )P jv i v 6-SToN6; kO A�7 Owner's Name Map/Parcel# A 7 Address Lot# Telephone# Installer's Name Designer's Name X6 AAr e S v P,Vey COS S 0(714 NS Address Address 410 g X ,N bu S'TR y v A'7 Telephone# Telephone# 00 SS Type of Building -` Lot Size 31 a sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinde jV0 Other-Type of Building _ No.of persons Showers ( ),Cafeteria ( ) Other Fixtures u Design Flow (min.required) 3 3 gpd Calculated design flow 0 Design flow provided 3!7 gpd Plan: Date /d — A3'00 /Number of sheets Revision Date Title 15 `fC+ S P W CA.C7.V L/4 Description of Soil(s) 07 Soil Evaluator Form No. 3 Name of Soil Evaluatomt ejDate of Evaluation a h 7- DESCRIPTION OF REPAIRS OR ALTERATIONS r . I The and rsigned as t� tallA b e described Individual'Sewage Disposal System in accordance with the provisions of TITLE 5 and fur er a ees to t o Ce e operation until a Certificate of Com 'ance been issued by the Board of Health. �t` � � Sig ed / (+' IX Date .aspsnrei No.- COMMONWEALTH OF MASSACHUSETTS FEE Board of Health, 10- `� 1� MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑Individual Component(s) 1Ll Complete System The uxfdersi ne hereby ce '�y that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned O b .IV® 1 at CR, P IN S p&: 7ZO has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and tth/e a proved design plans/as-built plans relating to application No. dated Approved Design Flow 3 7 (gpd) Installer i AM y� a Designer:M N kft Su✓oc", CO3n5QC�`'gj 4spector: ��lli alb �/ a e: A!! The issuance of this permit shall not be construed as a guarantee that the system w�7lunction as designed. 1 No. \i FEE COMMONWEALTH OF MASSACHUSETTS j fv+ Board of Health, S��a!-P� ,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission i hereby granted to; Construct( Reenpair(^)., Upgrade( ) Abandon( ) an individual sewage disposal system at // C N i PP/ "C-S 1-0 NE as described in the application for Disposal System Construction Permit NoV�6 ,i= �clated Provided: Construction shall be completed within three years of the date of this..permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date if "� ` :Board of alth. r pal Commonwealth of Massachusetts �� Me Ma Title 5 Official Inspection Form Subsurface Sewage Disposal System Form !.Not for Voluntary Assessments M 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 . page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information 41�gD- --� on the computer, use only the tab 1. Inspector: key to move your ^ �� cursor-do not Mike Hudson � �✓ d use the return Name of Inspector key. Septic-wiz Environmental Services Company Name 31 Midway Dr Company Address Centerville MA 02632 Citylrown State Zip Code 508-367-5669 Telephone Number License Number B. Certification . 1 _ I certifythat I have personally inspected the sewage disposal system at this addres and that-the P Y P 9 P Y �- information reported below is true, accurate and complete as of the time of the inspection. The-inspection was performed based oh my training and experience in the proper function and main enance.oif on site sewage disposal systems. 1 am a DEP approved system inspector pursuanf'to S tion-1-5i-340 of- Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority � 07/27/07 Insp or's Signat a 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. 112 Chipping Stone-T5 Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 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. 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 112 Chipping Stone-T5 Inspection•Q6106 Title 5 Official Inspection Fond: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 112_Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Cityrrown 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: ❑ 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. 112 Chipping Stone-T5 Inspection.0=6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage(Disposal System Form-Not for Voluntary Assessments M , 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owners Name information is required for every Marstons Mills MA 02648 07/20/07 page. Cityrrown 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 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 112 Chipping Stone-T5 Inspection•08106 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ��< 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. U IZSI 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. 112 Chipping Stone-T5 Inspection•MOB Title 5 Official Inspection Form:Subsurface Sewag e ge Disposal System•Page 5 of 15 Commonwealth of Massachusetts _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Chipping Stone Rd Property Address John& Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? 12SI LJ 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)] 112 Chipping Stone-T5 Inspection-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundryon a separate sewage system? if es separate inspection required] Y P 9 Y I Y P P q ] ❑ es ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usa e d 2005-282 GPD g ( Y g (gpd)): 2006-211 GPD Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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): 112 Chipping Stone-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal p g System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M ,.•''t 112 Chipping Stone Rd Property Address John& Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Water Pollution Control- Pumped 4/2/03, 04/05/05, 04/13/07 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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: 7 years, installed November 2000, via installation construction permit Were sewage odors detected when arriving at the site? ❑ Yes ® No 112 Chipping Stone-T5 Inspection-08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 15 r N, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M �y 112 Chipping Stone Rd Property Address John& Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints in excellent condition, vented properly, no sign of leaks Septic Tank(locate on site plan): Depth below grade: 13" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/Ayears Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 5'8'Wx10'6"Lx5'8"H - 1500 gallon Sludge depth: 4'10"(2'thickness) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness .25"or less 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 18" How were dimensions determined? measured stick w/flapper, tape,floodlight, mirror 112 Chipping Stone-T5 Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. CityfTown 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.): System has been pumped every 2 years, inlet and outlet tees in excellent condition, tank structurally sound, all effluent levels in relation to outlet invert are correct, no evidence of leaking in 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 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): 112 Chipping Stone-T5 Inspection-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Chipping Stone Rd Property Address John& Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cunt.) 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 leve'above outlet invert even w/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 is level, distribution to outlets even, no evidence of solids, no evidence of leakage, top of riser 26" below grade with plywood cover, d-box 51" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 112 Chipping Stone-T5 Inspection•08105 Title 5 Official Inspection Form:Subsurface Sewage sp g Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Chipping Stone Rd Property Address John& Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Citylfown 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: ® leaching chambers number: (2) 500 gallon ❑ 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.): loamy sand, no signs of hydraulic failure, no ponding, damp soil or abnormally lush vegetation 112 Chipping Stone-T5 Inspection-08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 15 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 page. Cityrrown 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.): I Privylocate on site n( e1 plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, i etc.): I 112 Chipping Stone-T5 Inspection-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 I Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 112 Chipping Stone Rd Property Address John&Danielle Miles Owner owner's Name information is Marstons Mills MA 02648 07/20/07 required for every - page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Chipping Stone Rd 1 W Front d 112 Chipping Stone Rd o, Marstons Mills, MA 02648 i A 3 Bedroom House B A 1 Q 1500 Gallon Septic Tank 2 O 3 A 1-15.9' B 1-25' D-Box 2-23.5' 2-- 3-34.5' 3-38' 4-38.5' 4-42' 5-39.8' 5-39' O O 5 4 (2) 500 Gallon Leath Chambers 112 Chipping Stone-T5 Inspection.oaW Title 5 Official lisped-F—Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 112 Chipping Stone Rd Property Address John & Danielle Miles Owner Owner's Name information is required for every Marstons Mills MA 02648 07/20/07 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 ground water: 10 + 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: 07/27/07 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Reviewed as-built and engineering plan on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed USGS topographic and water resource maps You must describe how you established the high ground water elevation: Reviewed perc test performed by Mike O'Loughlin 12/10/99 indicating no water-found at a depth of 120", reviewed USGS topographic and water resource maps, reviewed nearest surface water elevation with Google Earth satelite software. 112 Chipping Stone-T5 Inspection•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 15 COIVEVIONWEALTR OF MASSACHUSETTS EXECUTivE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIROMAENTAL PROTECTION 1TILE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 78 01d Town Road Hyannis Owner's Name: Linda Tetreaii1 t Owner's Address: Po Rox 7R4 zi Date of Inspection: !o-5:' d/&0a-7 Name of inspector:(please print)Sean Jones Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville. MA _ Telephone Number. 1 Sfl 1i 1 7 7 5-877'6- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system,at tltis address and that the information reported below is true,accurate and complete as of the time of the inspectiom The inspection was performed based on my training and experience in the proper function and maintenance of on sae sewage disposal systems.I am a EP approved system inspector pursuant to 5 ioa 1S340 o[Tdle S(310 CMR ISAtlti). Thesy - Conditionally Passes Y= Needs Further cation by the Local Approving Authority i Fat? c j N) Inspector's Si&ature: Ijate: / i `) The system inspector shalt submit a copy of this inspection retort to the Approving Authority(Board o Heatth'W DEP)within 30 days ofcompleting ahu inspeztiont.if the system u a shared system or has a design flo of Ifl,OU� gpd or greater,the inspector and the system owner shall submit the regott to the appropriate regional o cc of the DEP.The original should be seat to the system owner and copies`sent to the huger,if applicable,and th approxing authority. Notes and Comments ****Thu 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 6115/2000 page t Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued)- property Aadrem. 78 Old Town Road Hyannis Owner. Linda Tetreault Date of Inspection; v Inspection Summary: Cheek A,B,C,D or E/ALWAYS complete all of Section D A. 'Sy m Passes: I have not found any information which indicates that any of the far"lwe criteria desc ibed in 310 CMR 15.303 or in 310 CMR 15304 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,argon 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 grant determined"please explain. The septic tank is metal and over 20 years old"or the septic tank{whether metal or noi)is structurally q unsound,exhibits substantial infiltration or exfilt mtion 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 p'tpt(s)or due to a.broken,settled or uneven diStibtttion box.System will pass inspection if(with approval of Board of Healthy broken pipes)are replaced obsuucdun islewAved distribution box is leveled or replaced ND explain The system required pumping more than 4 tunes a year due to broken or obsmud pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)arc replaced obstruction is uma"A ND explain: ,Page 3 of I I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A " CERTIFICATION(continued) Property Address: 78 Old Town Road Hyannis Owner. Linda Tetre ult Date of Inspection: . C. Further Evaluation is Required by the Board of Health: AJI r 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 ctiviroomeaL. 1. System will pass unless Board of Health determines in accordance with 310 CN1R 1S.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 SO feet ofa border ng vegetated wetland or a salt marsh Z. 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 I 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 v�iell. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more ftoift a private water supply well" Method used to determiie dstm m •`This system passes if the well water analysis,performed at a DEP certified laboratory,for colifotm 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 cqual to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. 3 Page 4 of i i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 78 Old Town Road yannis Owner: Linda e reau Date of Inspection: io� e3/3ou� D. System Failure Criteria applicable to all systems: You must indieate')-res"or"no"to each of the following for 111 inspections: Yes No/- _ ��/1 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.outict invert due to an overloaded or clogged SAS or _ �� cesspool ( Liquid depth in cesspool is less than V below invert or.available volume is less than%day flow J Required pumping more than 4 times in the last year,NOT due to clogged or obstructed pipe(s).Number I of times pumped Any portion of the SAS.cesspool or privy is below high ground water elevation. J Any portion of cesspool or privy is within 100.1ect of a surface water supply or tributary to a surface / water supply. _ J 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 Kater 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 Haan 5 ppm,provided that no other failure criteria }� are triggered.A copy of the analysis must be attached to.this form.) 1`° (Yes/No)The system faits.l have determined that one or more ofthe 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 facilily with a design now of 10,000 gpd to 15,000 gpd- You must indicate either"yes'or"no"to each of the following: (111e following criteria apply to large systems in addition to the criteria above) yes fro .__ 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 I of a public water supply well I f you have answered"yes"to any question in Section E the systrnn is cnust-Wered a significant threat,or answered "yes"in Section D above the large system has faded.Tbt owrtcr or opuator of arty Urgi 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 av-ter should contact the appropriate regional Office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 78 Old Town Road Hyannis Owner•. It Date of Inspectloa: io G- ou Check if the following have been done.You must indicate"yes"or"nor 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? v' 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 unwvered,opened,and the interior of the tank inspected for the condition of the baffles ortees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? L _ 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: Ycs jno 1/ T Existing information.For example,a plan at the Hoard of Health. Determined in the field(if any of the failure criteria related to Pact C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)j 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION Property Address: 78 Old Town Road Hyannis Owner: Linda T!g:Ljpij it Date of Inspection• FLIOWCONDITIONS RESIDENTIAL Number of bedrooms(design). Number of bedrooms(actual): r DESIGN now based on 310 CMR 15103(for example:110 gpd x fl of bedrooms):z a 6PD Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no).,ram [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no): AoO Water meter readings,if available(last 2 years usage(gpd)): 0 6/0 5 to 0 6/0 7 — 278,250 Sump pump(yes or no): AoO Last date of occupancy. Gy f�e.►� COMMERCIALANDUSTRIAL AJ IA Type of establishment: Design flow(based on 310 CMR 15103): 9nd- Basis of design flow(seatsipersons/sgft,etc.). Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no)'- _ Nan-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: Was system pumped as part of the inspection(yes-or no).�� If yes,volume pumped: i j>;allons--How was quantity pumped deterrrrined? 5�2� Reason for pumping: TYPE OF SYSTEM J 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) _InnovativelAitcmative 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: (FR 5, - gCC.vpks 1>. c� c..�s�sbi� l of "'e l Were sewage odors detected when arriving at the site(yes or no):�Vr� 6 1'a&c 7 of 1 I OFFICIAL INSPECTION FORM—NO'P FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 old Town Road P Y Hyannis owner: Linda Tetreault Date of Inspection: ;;i i� BUILDING SEWER(locate on site plan) Dcpth below grade: 09, aterials of construction: cast iron ✓4Q PVC other(ex lain): Distance from private Hater supply Hell or suction lime: Comnj. ors(on condition of joints,venting,evidence of leakage,etc_): c�ea.a�s AC, �Qe tGcay'` SEPTIC TANK: {locate on site plan) Depot below grade: )F / Material of construction: ✓'1Mcrctt_natal—fiberglass—polyethylene _othct(explain) If tank is metal list age:_ Is agc confu-nted-by a Certificate of Compliance(yes or no):—(attach a copy of ccnificatc) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tcc or baffle: — Scum thickness: — Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outiet ice or baffle: -- _ How were dimensions detcrn fined: "3y c-cs ` /=,.e- G/,^ Comincats(on pumping recommendations,inlet and outlet tee or baffle coed ticn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): y n l et 7'e a 4.-�X o,�.t-}c� b-.FCIt !rti-d-4 c.I� c.� �-.. sera.� c�,•�!•'�s a=.r �ca.n s-c w4 s T GREASE TRAP. oca e on site plan) Dcpth below grade: Material of construction:_concrete_metal`fiberglass —0111cr (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: Dale of last pumping: Conuncnts(on pumping tcconuttctulatiuns.atlet mid outlet ice or baffle cot►ditiu:t,structural intcg rity,liquid revels as related to outlet invert,evidence of leakage,etc_): . . 7 ,c8of1I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE`VAGE DISPOSAL SYSTEM INSPECTION FORM I'ART C SYSTEM INFORMATION(continued) operty Address: 78 Old Town Road Hyannis Yncr: Linda Tetreault lit of lospectloa: 7 to Sf 010c7 GiIT or HOLDING TANK:N/ (tatik must be pumped at(unc of insptction)(locatc on site plan) epih below grade: .alcrial of construction: concrete metal fiberglass____polyethylene othet(cxplairr): imcnsions: apachy: gallons csign Flow. gallons/day lane present(yes or no), .larm level: Alarm in working order(yes or no): late of last pumping: .ornrnents(condition of alarm and float switches,ctc.): )ISTIUIIUTION BOX: if resent must be o cned locatc on site plan) ( p P )( p 1 :)cpth of liquid level above outlet invert: -onunents(note if box is level and distribution to outicts equal,any evidence of solids carryover,any evidence of cakagc into or out of box,etc.). / I'UAIP CliAl\1131;R: /(locate on site plan) Pumps in working order(yes or no):_ Alamis in working order(yes or no):, Conuncnts(note condition of pupip chamber,condition of pumps and appurtenances,etc_): Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 78 Old Town Road Hyannis Owner: Linda Tetreault Date of Inspection: SOIL ABSORPTION SYSTEM(SAS).. (locate on site pha,excavation not required) If SAS not located explain why: Type leaching pits,number._ leaching chambers,number: leaching galleries,number: ✓leaching trenches,number,length: I G 5- leaching Gelds,number,dimensions: overflow cesspool,number_ - innovative/alternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of pondin„damp soil,condition of vegetation, etc.):`` t CESSPOOLS: JJP 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 sctun 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: JV)Allocate 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.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address.• 78 Old Town Road Hyannis owner: Linda Tetreault- Date of Inspection: ion �do�a SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchiharks.Locate all wells within 100 feet.Locate where public water supply enters the building. � r t 3 1 AtJ AT-1 03— ! ' . d 3L D-gz* J3-3 �53" 10 Page 1 i of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address.• 78 Old Town Road yannis Owner. Linda Tetreault Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells . Estimated depth to ground water 5 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 propertylobservation hole within ISO 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: 11 Q LOT B-2 EXISTING WELL �'O- AS MAP- 27 0�/�' fJ E THAN 150 F OM PROPOSED LEACHING s� PLAN REF 549124 �./ LOT B-3 DEED REF AREA= 43,182E sq/ft i / ZONING RF A17AD SETBACKS. 1 / MAKBBY lb 20'-FR 0 0 AS LOT 44 10'— SD �y 99,0 _ �y HOUSE ,f49 10'-RR njti _ g9.5 9 SEPTIC IN REAR 6�9 / \ FLOOD ZONE: "C" ti OVERLAY PROTECTION ZONE. "CP" \\ SPUR "NE \ VENT 100.0 \� ° LOCUS MAP g0 AS LOT 45 HOUSE 153 SITE & ,SEWAGE PLAN SEPTIC I REAR ED pROPo M II / G. h\= PREPARED FOR ELEV= 100' (ASSUMED 3 BED SE W „l"�� / �0 { .`'y NE7� TACBOLT OF HYDRA NoU / JONA THAN & DANIELLE MILES ' ��� \ 4 ��,s'f� LOT B 3 CHIPPINGSTONE ROAD /�/ BARNSTABLE (MARSTONS MILLS, MA. \ \ \ \ w �4�/ 1 OCTOBER 23, 2000 \\ / 9 �oP AS LOT 46 v GRAPHIC SCALE � i w >c arn_ �cp SEPTIC IN REAR ao 0 20 ao so iso 9,0 Co 1 / A IN FEET ) 1 inch = 40 ft. 8,0 L YANKEE SURVEY CONSULTANTS 9 UNIT 1, 40B INDUSTRY ROAD .,.: \!�. P. 0. BOX 265 (D AS LOT 4 MARSTONS MILLS, MASS. 02648 HOUSE 181 TEL: 428—0055 FAX 420—5553 / SEPTIC IN REAR \ ; JOB,' 52511 CB SHEET I OF 2 r j ,101'-- Y TOP OF FOUNDATION r ` 20' MIN. 10' MIN. CONCRETE CO VERS 4" SCHEDULE 40 P. VC MIN. PITCH 1/8 PER FT. 2"LAYER OF VENT CONCRETE COVER WASHEDI STONE REQUIRED 6" MAX / / i / i , , , / / EL= 99 4" CAST IRON PIPE 6" MAX / � � � � � 6" MAX W (OR EQUAL MINIMUM PITCH 114 PER FT. CLEAN SAND FLOW LINE EL=95.5 INVERT 1MN- 14" 5' �20'-- o00 00000000000 og000 - 9775 ° 00 0 0 0 0 0 0 0 0 0 0 0 0 ° EL.—__ GS INVERT LEVEL 00 0 0 6 SUM o 0 0 0 0 0 0 0 0 0 0 0 0 00 INVERT BAFFLE EL = 9725 INVERT INVERT °0 0° o 0 0 0 0 0 0 0 0 0 0 0°o°° EL.=93 EL.=97.50 EL.= 95.75 _ EL.= 95.5 —_ 4• 4 (TO BE PLACED ON FIRM BASE) DISTRIBUTION (z) 500 CAL LEACH/NC CHAMBERS MECHANICALLY COMPACTED OR 6" OF SMAE BOX EL.= 95Z. _ GALLONS 710 BE WATER TESTED IF MORE THAN ONE OUTLET tz e' x 25' TRENCH FORMA TION NK SEPTIC TA PLACE ON 6" STONE 1-1/2"3/4" 7 SOIL ABSORPTION YI PROFILE OF DOUBLE WASHED S719 /NE SYSTEM / S) (SA l 1 T OM F TEST HOLE ELEV. = 89.5 SEWAGE DISPOSAL SYSTEM PE'RC. 9633 *NOTE: EXCAVATE To ELEV. B B�L 0�DO WN�71'J VERIFY MEDIUM SAND CONTACT HEALTH DEPT. FOR INSPECTION NOT TO SCALE OBSERVATION HOLE 2 ELEV.=_99.5 _ OBSER VA TION HOLE 1 ELEV.=_99.5' _ (PERCOLA TION RA TE _52_ MINI INCH AT 68" ) DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 0-2» O 0-3" O 2$$-4" A L/S IOYR. 4-4 3"-4" A L/S IOYR. 4-4 GENERAL NO TES 4"-32" Bw S/L 10 YR. 5-6 4"—36" Bw S/L IOYR. 5-6 32"—42' C1 L/S 2.5 Y 6-6 36"—46' Cl L/S 2.5 Y 6-6 .. 2.5 Y 8—4 ' C MED./SAND 2.5 Y 8—4 PERC. .P. 46 —120 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D E C MED./SAND z 42 -120 2 TITLE 5 AND THE TOWN OF _.BARNSL4R_LE____ RULES AND NO WATER ENCOUNTERED NO WATER ENCOUNTERED REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO SOIL TEST WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF SOIL 'I'ES T 12110199 SOIL TEST DONE BY MIKE O'LOUGHLIN 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN WITNESSED BY: DONNA MORANDI 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE DESIGN CA L C ULA TIONS.' USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 4 ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL NUMBER OF BEDROOMS . . . . . . . . 3 BE MORTERED IN PLACE. GARBAGE DISPOSAL . . . . . . . NO 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH INSTALL.- TOTAL ESTIMATED FLOW DEEDED OR ZONING REG ULA TIONS. OWNER/APPLICANT IS TO (2) 500 GAL LEACHING CHAMBERS ( 110__GAL/BR./DA Y x 3__— BR.) 330 GAL/DA Y OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. WITH 4' STONE ALL AROUND REQUIRED SEPTIC TANK CAPACITY 1500 GAL 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VA TION CONTRACTOR 12.8' X 25' SOIL CLASSIFICA TION . . . . . . . . 1 IS TO CALL "DIG— SAFE" AT 1—800—322—4844 AT LEAST 72 HOURS IN MEDIUM SAND DESIGN PERCOLATION RATE . . . . < 5 MIN./IN. PRIOR TO COMMENCING WORK ON SITE. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . . . . . . 74 GAL/DA Y/S.F. SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. LEACHING CAPACITY (AREA X RATE) 347 GAL/DA Y 8) PARCEL IS IN FLOOD ZONE __"C" . RESERVE LEACHING CAPACITY . . 347 GAL/DAY 9) LOT IS SHOWN ON ASSESSORS MAP __27 AS PARCELS 49 . (25X12.8X. 74)+(25+25f12.8+12.8)X2X. 74) S o z JOB NUMBER _ 52511_______ y It 4 r 3F COZOT ZD _._..._ _._ f Q �� � 2'b yJ► �aC Q't2oQN� L � M 11�— log III .Tq GG�bs2AC-�E 4 t R J&V-EE LE WAS e�— r F 01 ; i �i�l_ 2�-1 EA1 C? ...t I,0Y�7 4V Rki LAD S� e!,F—w tY 4-0 _O t�� �=--=�oti�i�>c aPac�cM•EN-r TO_._SOC E.L.117__mSttyraweE dp __MAlzST�7�,1r5._Mtl_l..S NCO. V-S-G 4$ .-:..t3E CCt ZOOM e7F4: cE ►�j�t�tZOOM Q - Ul V w�` t�ttil l t�l Gc -- 0 ... - l�l� OO .1� ® .. 5l:C Q iJ l� L O©1Z l�j-Qrt�1 0 �i tJs�T Peck AAeC,%A ( I W4M Qo_: -- `I l - - -_ _. __ �U�izE �l0'•�15,C--DES � t7ll�llt`1G�c _�Xl�Cld,lG� N�IYE = 1yT �.I2, -7CQ8 Z►w FUz• 7�8 2 Cd.c2 G1a.R AGE — f 1+26H1A`f �.M1 L`( Al wCAW-14T= 7s 1 *Ip uP Llyllsc� rz�. - N it Y. �Ala pN 767 SOIZ LLO �F�l�EtyCE ---- � t-(-Z -�N'lt�P(►;1C-�STUtiIF. t�c,.�[7 O F 12 S"C` LQc7� pL�t� Uv D.��.TO�Is AA(l l ,wa. 02�48 U5, :..PLA-i f2eir: t549-24 _ FtZp1.1'1' 6�crtz�l SE'Ct3 1�S 30', lGi'� (5' W9.(I 'Z O(I D-t�D tTl Ot-t E�l�iTl�•-1 G� ��� � �-� �� �1 W rx•.6� tlC�1.15 Z l%LY t4�t7GGP sNlNc�t.� -ro 1J.l�t� �}�CS'j"• }�0�15� 6tz`foNt'� LVI. 12ttX•tE t�p,f� '— ^' (s E�t�gZ'• ' � . : d tZQ�!'ftu.lCx (1tia��W�;IMT- Ot-1 � E � �l2" GLG�JTr CYcct�- TOP DQt.. FL. ii @ lfo"ot.. E � S _ •j, . : `, J, `u. •� •. �' \ �• � •• •2�Gr G.C-r.+�R°+T �Frs.�Pes,�r-��T�s -ta 1( u csYh BL7. `, / `i; \l(e,°t Y�.C_ t � t.�tS'T• OtJEg 4AtL -C�Ct? t Qc�c�F l..U-A s F--e D �„ �� q • GPCZ,M�°'c1L � t'2.i1 OgtS sa?1k1.4JG1 e,12 3�o xG�gy C ��„ "t`CPE" � GY t 2xlo sTuvs Al t_ SY7EV-10e Y°!a AA, WILL SE 4-KoLkTty 'FOP 4 MtlJl,. Rn.� y�1Q R�*�tEi�. 1�t.1D l(Z_" G`(P eV. p( 3 pLY 2x12 t2 2. b.U. 1=�T1"a.lOt2 CElt.11�CdtS WILL t3� 11JSU(.PE[E"i7 Q l.� �21 Fi3ccl. IuSL. ,`� �• � - . I USt NC4 2 L4.�{t:TLS o� R 21 �I3CsL �cCC'S L_.T TYC? ' I' EkCEC�T WHERE 1 tERS FOOVtT�E e*IL(kSG r—_ Cl a � sTRucrUKE. RAk Z WtLL W-Cf-tv E OMS. O -; LsgER•. ALL IWSOL. wtLL 3E Co\IMO-;> Wr%k 'TYPE x AM t_ A41:tZ (EQ rtZ„6,fF gp a � uj — . U L z ��.t.�E. I I I I I I-I.��. —� �l-� i•�• c�o,,K�, sA�c.F<I I I 2"taUly ( I I I I -�—�-- Y--f-'+tee��s ea +vl 3cr�o test cd�c. stv a 7 I usL.��� i I i I c 1 �(�at;17 ?VID�R�Ct-k I3 ?cell �xGo- z9v!x2��A1 wwF 't-o �4tOW lu6ut,A�TtNC'� P�1� I I I I � �----� �«tF. w( BL Ott=flit"=' ���=1�1=t� trtuc�5 �lot�av 2- 4rs ca,�T. -rYP � 7t ct .. �Ccis• i�EtNF• `� UNCKTUS2EEt7 `Atl� Q�U_ 1 P W' � �A,eS 48°oc . VEi�T p�DD MtON IZ2 � �C �� � CT�rn) SELL® t2E51DE�iCE t LZ Gt-41PPlh1C��T4t-.1ir t�.o�,Q ' �dP�ST4tJ� /VLILIry AIIA O2G48 ® -TIZkMSVEZSf— SFLCT-tOt4 THOU CEO ZME Ax�sso¢� l aT : 27-49 PtA tit r��F ri4�i-24 'I sc 1, ly' ,fl�i' oCT.t7°ZOtO I Zvl..t1►..t11•. t2� 6y tL'7C�l7 Zc'J'I.IE: rrG°a �® - �' i�VtSEc� 63�t3�2otI