Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0076 CHUCKLES WAY - Health
76 Chuckles Way,Marstons Mills A= 101 - 136 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 rti Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below,is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ■❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey "."=�"'D �����.�.�. 12 . - -11-19 Oale:3Df 9.12.11015T.R Uv OV Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•f Pag/e 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �y p I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or mores stem components as described in the"Conditional Pass"section need to be Y P replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 'T 1. System Form Not for Voluntary Subsurface Sewage Disposal S - Assessments ry 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts I , Title 5 Official Inspection Form r l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way V Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts i Ti Sewage tle 5Official Inspection Form p ystem Form -Not for Voluntary Assessments 76 Chuckles Way v� Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ n 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.] ❑ 0 , The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply I ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way V Property Address Karen Langfield Owner Owners Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? I ❑ ❑ 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 facilityand occupants if different from owner provided with ❑ 0 owner( p ) information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 F c Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way u� Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 350/GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes E No Does residence have a water treatment unit? ❑ Yes R No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes RI No Seasonal use? ❑ Yes [g No See below Water meter readings, if available (last 2 years usage(gpd)): Detail: 2018- 39,000gallons 2019- 41,000gallons Sump pump? ❑ Yes K No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts l� Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): h 3. Pumping Records: Source of information: Owner- last pumped Oct. 2014 Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ . Privy ElShared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New SAS added in 2008 per plans Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Distance from private water supply well or suction line: Town waterfeet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 611 Sludge depth: 3011 Distance from top of sludge to bottom of outlet tee or baffle Orr Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form I'I ,Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way u Property Address Karen Langfield Owner Owners Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from o top scum of to to of outlet tee or baffle p Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 cam, Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (�/ 4 1/ 76 Chuckles Way V� Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Orr Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way u Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (3)500 gallon chambers Q leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Leaching was dry when viewed with no evidence of past back up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way V� Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c , Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form "Pl�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately xJIiYY'.1t%AA ail ll.-I)RYd.Y`A LocATioN *'7z' GA,,.j rAf �. SFwAC"rI #. paar..:.y7a • _ VILLAGE // ILLSASSIESS0R s,MAP&PARCEL /0/ INSTIALLEJ.S'NAME&P TL7NE NO, +TAG_ .X�+ /�d Gey 's�r�=7; r�•^� C✓`��7�`5'S� SEVVIC TANK C.AJRAt I i'Y'_ - L,I ACHING FACILITY-(type) 3�lt±�—e-A..—.4— (si:us) /c7Y 31 .Y-; - ... IVC):C.3F'Hl`I�ItC)C7MS � ..... f PERA41T DATE: // 5'G�_._.._. <:f NWLIANC'I DATE.-—` .Y._..._l�Jrs Separation Distarme Between the: Mea morn Adjusted Grovudwatra Table to the Bottom of3Leazhinl;Facility Private Watcr SvxWy Well and.l.taefdrja-Fsei ity(11'any wells exist+on. AW or widtin 200 feet of Waching,facility): Edge of Wetland and Ixacbing,Facility(tP my wedands exist within' 300 feet of last fling facility). FL7RNISftTI7 B1. A'' 13 M �.. J+• -3 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �= ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Chuckles Way Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water R Check cellar OR Shallow wells . Estimated depth to high ground water: No GW @ 132" feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked, date of design plan reviewed: Oct-13-2008Date ❑ 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l; 76 Chuckles Way V Property Address Karen Langfield Owner Owner's Name information is Marstons Mills Ma 02648 12-11-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. 0■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed R■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 rj/✓ TOWN OF BARNSTABLE I.00ATION 4 0o ' / . wmvj tl!& SEWAGE# /Q VIL-LAGE 44.lW1dB, . . .._ ASSESSOR'S MAP& LOTAI—liC INSTALLER'S NAME&PHONE NO, C5p a&43K SEPTIC'TANKCAPACITY. a{' LEACHING FACILITY:(gPe) R//f (size) _ NO:OF. BEDROOMS 3 PRIVATE WELL OR LIC WATER` . BUILDER ;R OWNER DATE PERMIT ISSUED; DATE COMPLIANCE ISSUED: VARIANCE GRANTER: Yes . ._ . Na 33 e v CERTIFIED SEPTIC SYSTEM REFG d "e , cr °- LOCATION 76 CHUCKLES WAY MARSTONS MILLS, MA 02648 MAP 101 PARCEL 136 LOT 19 _ --- PREPARED FOR SELLER MR. WILLIAM B . DOOLEY, III 76 CHUCKLES WAY MARSTONS MILLS, MA 02648 BUYER MR. AND MRS . DAVID W . LANGFIELD 1095 FALMOUTH ROAD HYANNIS, MA 02601 PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE , MA 02632 508-778-1472 AL Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of t E P Environmental Protection Trudy Cox@ William F.Wild swoul ry Gammon David B.Struhs Argeo Paul Cailuccl commmawwr U.fiOMM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: /�v G/�Ue=sC(�/LS Ge/✓?Y, Address of Owner. Date of Inspection: %�o�v/�G S If different) Name of Inspecton Company Name,Address and Telephone Number. l✓o A"X as o 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: --Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority —_ Fails Inspector's Signature: � 24�z Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of complaUng 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. INSPECTION SUMMARY: Check A B,C,or D: A] SYSTEM PASSES: I bave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,pesom Indicate m no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined",explain why not) _ The septic tank is metal, 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 yonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)SW1049 • Telephone(617)M-5500 CJ Pnmed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: ?L L/Nv G�e A S wf+7 ��2SlGN/S iJ/G C f Owner: 4,7/t?. L�/GC�/a�/ /� . G����%/�r ZZ7- Date of Inspection: B1 SYSTEM CONDITIONALLY PASSES (continued) 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 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 C1 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 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 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 APPROPRIATE) DETERffiNE9 THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address 74, Owner. *.E'. Date of Inspection: DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an 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 ll2 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 Soil Absorption System. cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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 privv 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 eoliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: 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: 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 (1WPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address 76 Owner. Date of.Inspeoti on: Chwk if the following have been done: i_11trmping information was requested of the owner, occupant, and Board of Health. Noae 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. _L--As built plans have been obtained and examined. Note if they are not available with N/A. _.L.1he facility or dwelling was inspected for signs of sewage back-up. ,-The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. All system components,46 uding the Soil Absorption System. have been located on the site. L-The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or teas,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. _Ll�ha size and location of the Soil Absorption System on the site has been determined based on existing information or apprwdmated by non-intrusive methods. In facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 /L U Owner. Al( Date of Inspection: FLOW CONDITIONS RE8IDEN1'IAL• Deep fl"w:ins Number of bedrooms: Number of current residents: Garbage grinder(yes or no):—&P Laundry ocnnected to system(,yes or no):&15' Seasonal an(Tea or no): '�� Water meter readings,if available: i�'lS'� /%e,OCx" GAL Last date of occupancy:j22f,� c�JL Y COMMERCIAL/INDUSTRIAL- Type of establishment: Design flow:_,g illons/day Green 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: OTHER(Describe) last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_1/1 If yes,volume pumped: gallons Reason for pumping. TYP&Og SYSTEM Septic tankAhstribution box/soil absorption system Singh ossspool Overflow cesspool Privy Shared system(Tea or no) (if yes,attach previous inspection records, if any) Other(explain) APPROZDIATE AGE of all components, date installed(if known)and source of information: Sewer odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7Gj- Owaor.. /7-. Gi cr. /d. IJov�. Y 77T Date of Inspection: / SEPTIC TANK 1� (loots on site plan) Depth below gmde: 93 4—/9.•s Ustanal of construction: concrete_metal_FRP_other(explam) Dimensions Sludge depth:_ Distance 6ont top of sludge to bottom of outlet tee or baffler/e` Scum thiclmeaa: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to'bottom of outlet tee or baffle: f� Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) T1,CA5 v ry,4--r GREASE TRAP: i (locate on site plan) Depth below grade: MatwW of construction:_concrete_metal_FRP_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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Pmperty Address: 7G c��r�.�L�s Owner. Date of Inspection: y/ate/yt- TIGHT OR HOLDING TANK (locate an site plan) Depth below grade: Materiel of construction:tion:_concrete_metal_FRP _other(explam) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: I Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) �, v�xr� .��,� s�?��._✓.�Tiv;� ,rim si�,� c;Y- G�.�j�c.= T/f,�'2� �i��- - Ujpi�,�r PUMP aLMIBER:__� (locate on sits plan) pumps in waridng oxder.(yes or no) . Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oantinued) Property Address: 26 Owner. �liQ Lt/mil !�?/1.�SlGi!/S Vz GS Date of Impaction: el/�1s< SOM ABSORPTION SYSTEM (SAS): y" (locate an Site plat.if possible;excavation not required,but may be approximated by non-intrusive methods) If not dsterminad to be present, explain: Type: I"thing pits, number: lssching chambers,number:_ leaching galleries, number: leaching trenches,number,length: hacking fields,number, dimensions: overflow cesspool, number: Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.)_%, ' �%T Gr/iys pv2 Jd l�'is�t o,� 74�a CESSPOOLS: (locate an site plan) Number and configuration: Depthtop of liquid to islet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Material of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PBIV]L• (locate on'site plan) Material of mumuction: Dimensions: Depth of solids: Comments:(note oondition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address; Owner. Date of Inspection: ' 8XXTCH OF SEWAGE DISPOSAL SYSTEM: iaehzde ties to at least two permanent references landmarks or benchmarks locate all wells within 100, DEPTH TO GROUNDWATER i Depth to Ro®dwater. /J fi feet method of dstarmiaatioa or appr=imation: 13fIf?/>T/li;LE' 6-15 (revised 11/03/95) 9 Town of Barnstable P# Department of Regulatory Services ' r Public He' lth Division — � Date r, 06 D4?-,_ �b'yEo "�� 200 M ' Street,Hyannis MA 02601 Date Scheduled. ime Fee Pd. 00 r Dt� Soil Suitability Assessment for Sewage Di posal n Performed By:. Z ✓ OeAfor Y WitnessedBy: ) LOCATION& G NERAL INFORMATION I Location Address -r (Z `y Owner's Name Address -T Assessor's Map/Parcel: \O N (0 Engineer's Name. cj` NEW CONSTRUCTION REPAIR Telephone#-- Land Use Slopes(4b) L AA r:ee Surface Stoncs_ n Distances from: Open Water Body 1 �i� ft Possible Wet Area \ tv ft Drinking Water Well i. _ft Drainage Way ft Property Line*'. l o ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands In proximity to holes) 0� L IN \ 1 00 � N � m IV ys _ t7t O rr*1 r Parent material(geologic) y.,.�_ Depth to Bedrock. Depth to Groundwater. Standing Water in Hole: tAo Weeping from Pit Face Estimated Seasonal High Groundwater 7 I l ETERNIINATIONIFOR SEASONAL HIGH WATER TABLE Method Used: *ft- 'ZW-0 V4. '1'r('—J%-%Mt rGr4,s. Depth Observed standing in obs.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole, in, Oroundwater Adjustment ft. Index Well# Reading Date: Index Well level Adl,factor— Adj.Groundwater level, ,z PERCOLATION TEST Date; V 6 nme.�;�ti Observation Hole# � Time at 9" tt Depth of Perc _ Time at 6" Stan Pre-soak Time @ it:\0 Time(9"•6" End Pre-soak �. t• Z�4 �a'�^ . U?.�A'Csl'\"�' �"" '�A't�b1LA•�'G` Rate Min./Inch L Z Site Suitability Assessment: Site Pass ' Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q MPT10PERCFORM.DOC .. .. .....w.w..-. w.a'..•.-.� .+..G..•a..r.«.: +...:.r,!.+f.r..w..w.... Jr.yn'tiMarrfrwr-.r.1mv:,xw:n...:.a.«r+:aww✓<.i.y..w.wr..:ww.s.ra..nr«m+rw.m..+r.r.:_u.rwwwrtM.+Wrw.w.w.r+M.v+..,.yv......reen.W,l::, . DEEP.OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Cons it v �L ®vt8et� t:(Ww' Z.4 LLD -f�2'7,,,J (,-,5 l i7 t to l 1 L ZYd Tao r- dyt, l - t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil er Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ons'-.. % 2 ''�7 u� L `> tZ 4 L L:l. J �• DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. o Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Flood Insurance Rate Mau: Above 500 year flood boundary No_ Yes—Z Within 500 year boundary No ._._ Within 100 year flood boundary No:1L� Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervioys material exist in all areas observed throughout the area proposed for the soil absorption system? r-� If not,what is the depth of naturally occurring per tous material? __ Certification I certify that on y (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertis nd experience described in 310 CMR 15.017. n / 8 Signature Q:\SEpTIaPERCFORM.DOC J TOWN OF BARNSTABLE LOCATION �+'7lo C1yc rlff G✓G Li SEWAGE# 73 11 VILLAGEVdr)fZSSESSOR'S MAP&PARCEL /0/ INSTALLER'S NAME&PHONE NO. �T, C, /IR /fo Go�, s7r��7; u�, (✓rR�Yafl 9595 SEPTIC TANK CAPACITY 100�; Ex•'r�:ay y LEACHING FACILITY:(type) 3-6-05 -,A,..,, (size) /0 X 3/ Ya NO.OF BEDROOMS 3 OWNER Lu�S -F`r/4 PERMIT DATE: COMPLIANCE DATE: _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 1 a 1 rY %4 Y i 3' 3e ETI - 3) � ' Ifa 3 Q 33 s IVA" 3 10 No Z < D FEE D v COMMONWEALTH OF MASSACHUSETTS ' Board of Health,'1 �i�R]v�Jr.-* -,,— .MA, APPLICATION FOR DISPOSAL SYSHM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location -1 G G�}U rAv Owner's Name Map/Parcel# j Address (� C► Lot# 101Telephone# Installer's Name M Designer's Name 7�"v �hSTEPREXi Address Address 42 CANTERBURY LANE Telephone# �G7� �a8_ �S ys- Telephone# 508/540-2 534 Type of Building Lot Size 1, sq.ft. elli o.of Bedrooms Garbage grinder( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) S$0 gpd Calculated design flow Design flow provided SrL9 gpd Plan: Date 1 e .011 - o ?7 Number of sheets Z Revision Date Title �rdt (.. 1�1'�L-t L7�7r't� �I�A�t�ti '�i9IL.. `T 1® C-41,4 1,"11 AJJ Description ofSoil(s) " L-M 6 Soil Evaluator Form No. t -;T_ Name of Soil Evaluator S Date of Evaluation `A Es[o-b g DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr s o t to pl ce the system in operation until a Certificate of Compliance has been issued by the Board of Health. Sig Date # Inspections J No. �00 E `7 '7© a' .>,. ,e, P FEE /D 0 r CON' M NWEALTH OF MASSACHUSETTS ..t Y Board of Health,'1 ��i01,\,5--V,31 MA. APPLICATION FOR IBIS ®SAL SYSTEM CONSTRUCTION PERMIT F Application for a Permit to Construct( ) Repair(Vy Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location "( (� G��ta , Owner's Name �� ✓Ta��L Map/Parcel# 0 ` j 5- Address I J Lot# 101 Telephone# 1 Installer's Name J" �u J7 Cam, stYv f{,on Designer's NaEPAEti 11203711 As Address Address 42 CANTERBURY LANE PGt . y 33't' W-,-s7;-s �1,/1 Telephone# r570g) W8_ 9S ys- Telephone# 508/540-2534 Type eoof�Building Lot Size l� � sq.ft. Dw� elllin,g�No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow(min.required) 3$0 gpd Calculated design flow I? Design flow provided S O gpd Plan: Date a 1 1 I — o Number of sheets 2 Revision Date Title �r o � L21'�L 0��'9,a—e._ �i� � 'C��+�--- �o C 41Zj Description of Soil(s) 5��t-Sc, Soil Evaluator Form No. k -r -�l» !k Name of Soil Evaluator 5.71t!LrL Date of Evaluation j b- 6 L b 9N DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreCo not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signe Date Inspections /l a �� ! COMMONWEALT14 OF MASSACIIUSETTS FEE //v� Board of Health, l-✓ram 5/c,dk Aq. , MA. CERTIFICATE OF COMPLIANCE Description of Work: O'Individual Component(s) . ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (,1�,Upgraded ( ),Abandoned ( ) by: ). �, / �4 A/V at r has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.;Q-0 —q P dated / �G K . Approved Design Flow e d (gpd) Installer C'• �� �0 1 p Designer: /Yi�/r t�ffoC_ Inspector / 1 Date: i— The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. Q[) FEE �Q d COMMONWEALTH OF MASSACHUSETTS Board of Health, Arr✓1 S/6;,Z1 Na. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade(✓) Abandon( ) an individual sewage disposal system at ?VI/ 4CAV41fle5 61f/uc-9 as described in the application for Disposal System Construction Permit No.3EpR_LI7C,dated Provided: Construction shall be completed J1within three years of the date of-this permit All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date ° Board of Helth I� - Town of:Barnstable Regulatory Services Thomas F. Geiler,Director t 13,MxsrnBM • MAS& ��$ Public Health Division 1659. Thomas McKean;Director 200 Main Street,Hyannis,MA 02601 Office:. 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 1� k-5 Sewage Permit# 4170 Assessor's Map\Parcel aoC - L Designer: Installer: ,k SILIMEN, J- - - ASSOCIATES Address: 42 CANTERBURY LANE ��.ddress: ZP IjaV ? 9 1 ®AST FALMOUTH .ASSAGHUSe�Tn J 608/640-2634 On //- /3- 0 ;�yL.��7 was issued a permit to install a (date) (installer) septic system at 1(Q t, I based on a design drawn by (address) 5,,,,1r, dated (d signer) OI certify that the septic system referenced above was installed substantially according to- the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required)was inspected and the soils were found satisfactory. SN OF f,T��s� .► P�SN OF AfgsS CHRISTINE 4�``' �•OQ�G`STERFpcyGd,•� (Installer's Signature) o fAIRNENY �, o� STEPHEN v No. 926 U 4 `' DOYLE N ► AFCISTE��O i �. #37559 � ► SANITARkaN i►► �Fc� `��Q ►► 0 SUR (Designer's Si ature)V (Affix Designer's Stamp PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL-NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc No...�VL=,, ¢ L-0-7 v3 Fu$......��C.2........... P� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH b ...�6......�.................OF. (a2...9�5_- ..._.._.._........_.._..._.............._. Lo Appitra#tun for Uhiposaf Works Tonstrurttun Prrutit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: ... .. � �.: ... �.�....1�_1.��� �►,..:s f ,�....s .._.�.. ................................................•.. a"i ,Addresy�-- . (�(f t No --......... r D _.._. Address ........_......................a ••-•.. .-•-----......._.. Installer Address UType of Building ,70 °� Size Lot...A.:0593-----Sq. fFet Dwelling—No. of Bedrooms............................................Expansion Attic ((VCR Garbage Grinder aA4 Other—Type of Building No. of persons............................ Showers g --------•------•------------ P ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------•--------------•----------•-•----------------•••-•--•••------------••-••••-••••-•------........_..--•-----•--- Design Flow _gallons per person per day. Total daily tflow___-----vim_ gallons. w s WSeptic Tank—Liquid*capacity.11M_gallons Length WidthA_1Q... Diameter__.____..=_. Depth.. .-:6_. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___...�.----------- Diameter.......B--....... Dept below inlet...6a........... Total leaching area...MO...sq. ft. z Dosin tank Other Distribution box (Yo� Percolation Test Results Performed by--- Ar.&TE .. r._NV _.)- L__________________ Date..... `_ ____.__.__._._... Test Pit No. I.....�-Z__minutes per inch Depth of Test Pit-_kZ........ Depth to ground water._ A.�lkWM 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---•-- -------------- . . ....--------- -`ODescription of .. .-F0_SA ...................................................... x c, ------------------------------------------------------------------------------------------------------------------------------------•------------•-------------w 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 TITLE 5 of the State Environmental Code—The undersigned further agrees no vto place the st�emin era i until a Cer ' 'cate Coe has been issue by the board of healtho j Signed .................. .......... ..... ------.//��1 ....- Date plicati Approved BY ........ �. Date Application Disapproved for the following reasons- ---------------- -------------- - ------------------------------ .------.........------------------------------- .................... ...............................---.. .-.------------------ ---------------------------------------- . --........... Date Permit No. ��j e -..-------------------- ��J..... Issued .........................................................---------- Date T� 1 No.. �1.-., D.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................... ... ...................--•------••---..._......_.._................. Appliration for Disposal Works Tonstrnrtinn Vrrmit Application is hereby made for a Permit to Construct (, ) or Repair ( ) an Individual Sewage Disposal System at: ( f r 1 L-C_5\ NC) ..... .......:. ...(-_f_-.. _ r NLo.a' Addr.e oto. ............................. ...-------.....--------.._.... -----..... --- - Address a .._.._./.........................••---....._...._....-•------_.........._.....•---•--•-•- --•-.. .-.-.-. Installer Address } U Type of Building -� Size Lot_______...�....I ...........Sq. feet Dwelling—No. of Bedrooms.............................................Expansion Attic (ti ) Garbage Grinder (k+),I aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----•--------------------------t--•-----------------.10--•-------•------•----------------•--------•----._...-•------------------•-•--------......__.. W Design Flow________.__ ..............................gallons per person per day. Total daily flow......... .........................gallons. WSeptic Tank—Liquid capacity_3q..f�gallons Length��_: ____ Width�.'_�U,_. Diameter__----....._ Depth_5____S.. x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...._---------------- Diameter.___.__P-'�......... Depth below inlet.... Total leaching area____-% ..sq. ft. Z Other Distribution box (yC)'> Dosingtank ) �x'7" 1\ ' lu'4C� � Percolation Test Results Performed by---=-------------=--------.............................................. Date-----•-••------•--...--------�•------- Test Pit No. 1_._.__ 7 __minutesperinch Depth of Test Pit__.�_�--_____.___ Depth to ground water_.���-:`_`=..... 44 Test Pit No. 2................minutes per inch 'Depth of Test Pit.................... Depth to ground water........................ -----------------------------------•-•-•---•_--.-• --- ......................................................... O Description of Soil__( _ _..v �_� �,a?�5o1;::-.Z-�`Z._.1`''� --5-ra-!._(. 1 x V -•----••--------------------------------------------------••---._...--------------•------•----------•--••-------------•-....--------•---•--•----------._.--•------------------------•.....-------._.._.. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------._...._---••---- V Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ --------------------------------------------------------------------------------------------------------------------------------------•---------------------•-------------•-------------•-------••------ Agreement: The undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in-accordance with the provisions of TITLE 5 of the tate Environme tal Code—The undersigned further agrees not to place the tem in o ra I until a Cer ' ' ate o CoB as been issue by the board of health. Signed ........... ................................ -- ------------------- ................................... ---------- ...... Dare plicatio Approved By �.... � �.�, ^ ,-=-�----------------------- /..1...-...r/.:...�t.G. Dare Application Disapproved for the following reasons- ---------------------------------------------------- ------------------------------------------------------------------------------ ---------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------.............. --------- ........................................ ----- ------------------------------- �Permit No. ------ r�� -... .fj Issued -------------------- - - -- --..................--`e------ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �L S iz�.- ....................----11-.... OF .... �-' C.•, Certificate of Contylian.ce TH S 0 RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----- ... v!3--1. --------------------------------------------------------------------------------------------------- . ' / Insr Iler OC at .............................- ----------*-------------------------------------------------- ............................................................ ------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ....s'O.-..-:.;, .O...11........ dated ................................................ THE ISSUANCE QF THIS CERTIFICATE SHALL NOT BE CONSTR AS G9ARANTEE THAT THE . SYSTEM WILL FU ION SAAfTISFACTORY. Q DATE----------------` 1..`� e' ..------......-- . ......... Inspector THE COMMONWEALTH OF MASSACHUSETTS _ BOAR'D2,OF HEALTH ......................I......... .......................................... ....................... No. :.,1. 0 FEE.....&............. Disposal IVrk� inn trnrtuan rrmit Permissionis hereby granted �-----------------------------............................................................................................... to Construct (/<,) or,Repa_ir (`�) an Individual Sewage Dis o ystem at No. -L` 1 r•_j_::,.?C:_� e.`?..\?�,1 `. :.5,C:t..................... . .... . ......... treet q as shown on the application for Disposal Works Construction Permit No.,l(f__S U_ Dated.......................................... 3 Board of Health * -- ---�o................................. DATE................ ----- FORM 1255 HOBBS.& WARREN. INC., PUBLISHERS �_.►.10...,.GAM-aA�� I>dl L�{ FLOW _ 110 r- �MF—rt c T44-4 K = 330,e 4-9 5 G.R�. r _`—� I h 3 .go IOOQ . GAL. ..IL _ 21SPOSAL' PIT •;.`USE tUOd Gam... `6 ;(cam. SF ,� 2,5 : 375 G.P.D. ✓ 7 41 A SO rs>.R TOTAL �ESIG�1 = d25 G.pD. -0�P°!�' �- ?'OT&t- �,dtt_-f FLOW = 3306.PD. 'z PIZ O 1 12 QLQTIOU tZl�TE 02 L>✓SS. 1 •- SN OF Z4. NAP RTER .r SN OF o SULLIVAN V RICHARD NO. 29733 A. / U,! i 0 RAXTER w / � r. , a p o zaoa� i l o I.13y 3 / ----- �. aT CN U ^ 76 ® 4rPIPb 'Box I6 SEAT IC , t... ... IWV. l �' IC> � l Doo le6,A_ l T'A�tK E ' 'L GAL. 'uV' tuv.PIT •., Y T ' {� t ITS WITtJ A f Srows- E 60.E -, � ,, CECZTIFiI_p pl.dT PL./��l PQ-oT=-t LEa LOCATION ,I( /�ttGe, ONE - .. 1::GU1ZTl4=�{ 7NAT' TI-1G 0014T>AT/0.1t SLaow►J PLI�.I`l Rt.�'iriZct.1GE CC�VWLIl5 W ►"t R TI4` SI DG.Lt►-I� �tia SE'r>✓��ct< �'c4�1�ENccuT.; OP 'iowt.l ct=' -BA2I ,1rAP, - A�ZD ',5 NITT" LrxArt��. /l/J l't"141 N .�E r'r�;-7',3/� �s A t N (�, �•C G: L{.��j[t-� � ::l'� • � D� 4- -� XTCIZ 4 uYE t�lG_ -.-r---� t REGIS�tt2�� 1-AI�iG SUeVcYoc: Tl-{l5 M-AI-! I,-� tJOT LAy[:p ot..y Ae.! OSTE2Vll,lL- o A,(ASS� �uSf�:J:✓LC_t�l; ;U��,�/t_�' � T+�L_ UF�"S�T�, 5 ts.1LD i ApRI_ C_t�.!el f' t3 C U L�� Tc, i r.=1't_c��t.t t►J l'= l o''C' l_t�i�.; �1 T' �, .G - EXISTING LEACH PIT' $_SOIL OBSERVATION -PIT " HUBAEL POND OTO BE ABANDONED G BURIED GAS BURIED .ELECTRIC �N' S £er. , E . . ti4 -, Wb EXISTING WATER 62.11EXISTING SPOT`ELEV. SERVICE- LINE -X. PAR EXISTING HYDRANT 62 EXISTING CONTOUR a.. 0 va : S� 2 p>, 2 f. 4 LOT 19 7 LOCUS. s� 14 993t S.F: oA o ST bF A e.. Nc. . h 74 ^e . E 75 �. 4 � . : ..•,- ..p . , .. ....,,. _ ;.;r , ;:. REFERENCE CERT ;1 ASSESSORS.DATA: 4,2537 MAP.101 PARCEL 136 ZONING DISTRICT RP2 ory Ri =a W ,• - ,F.. D VERlA Y DISTRICT. GP RPOD a , 74 FEMA .DATA.• ZONE C r. z PANEL 250001 0015 C AND ZONE..II MAP 'REV: AIIG. 19,. 1985 04i h• 20' TO K,'y/ h Sy.OF jy LOCUS ADDRESS. •: w:.:• 4/,. .. .,,. . o -s 76: CHUCKLES WA'Y MARSTONS MILLS CHRISTINE �G 8� ? s FAIRNENY Gig G r •. , +� • o� . . 1p� sEE zoo• o ,- z �, , ,. Q,� SHEET 1 QF 2 EXISTING <• .z . STOUT x. , o , . �• .1000. GALLON 2p. :,... •.. NOTE s 72 4, :•: TANK TO REMAIN k e. ,N m Q o -o >SE'PTIC UPGIIDE' PLAN SHEET 2 2�s �� �3- A&A�q�® J •,. / ss; Prepared For.- ,A PROPOSED .:._.... . Fp . � ®' Q 3 z ,... _ S.A.S. � 76 �T T Tw 7� �r -�-AT V' TEST DATE: 10-06-08 _ n. I 1 sIF mot: CL 1 cJ �.I�Li� 4'4' 1 CHAMBER , SOIL EVALUATOR: I S. DOYLE WITNESSED BY: D. 'MIORANDI IRS DESIGN: c,�� c: �, . ". 4 � V pOYLE �. T.P: #1 PERC <2 M/INCH . . T.P.:. #2.PERC. <2 M/INCH L. 72s' EL. 72.s' 4�/ > OTC n D o y`�r® Mars tOPS Mllls, AMssa ch use t is „A., SL 10YR 3/2 A„ SL 10YR..3/2 . �� 5 5" 1» _ 30' D �w FILL 13,-2008 FILL LL Scale:. ate• October 24 24 J �'p.�►3 � 0 "ew Ls 10YR 4j6 'Bw Ls 1oYR 4j6 { Prepared By. 60"(EL. 67s') so"(EL. 67.6') Stephen J Doyle and Associates C FINE C. FINE v. GRAPHIC SCALE' 4,2 Canterbury. Lane,. E! Falmouth, MA 02536 SAND �PE Rc ® s4SAND - _ Tclaphon e:. 508/540--•2534 30 0 15 30 60 120 2.5Y'7/4 2.5Y 7/4 .V�Ta S -z O -ZE3-z c::> C � I EL. s1.6' 132 132 I . NOG WATER OR NO G/WATER OR IN FEET REDOXIMORPHIC FEATURES REDOXIMORPHIC FEATURES 1 inch = 30 ft._ LN0: DA.TE -DESCRIPTION . - . BY " I � T 7� 7�:r _ I 7� � ram.r �o T.O.F. = 74.12 of �oJ 1L� 1 U/1L b JL ' 1L /l �1C� V JL JLs A JL . 7 FINISHED GRADE EL. 72.7'f ' 6„ ,, 1/8 TO 1/2 DOUBLE WASHED STONE © 3" THICK OR GEOTEXTILE FABRIC 6 20 RISER 20 FINISHED GRADE .EL.. 7 FINISHED GRADE EL.. 72.5't 15' .HOR►ZONTAL 2.5 f '. Dla. . Dla: ,, NO BREAKOUT >'of io -INV EL — EXISTING... RISER 8:5 ��1 EL: :io a' TO REMAIN ER El. 69.53 _. { 10" Min. 14 Min: INV EL a °° o o v o D o e ° . El.. 66. 70 I1VV EL — — INV EL INV EL Min. 6 68: 70' 8' INV EL 3/4" _ .1 1 69.55'. Below Flow Line 69.301. Sum , 69 20 69.00 1 1 Q L Liquid Level 48" DOUBLE .WASHED .STONE r 6" Stone �. 34 a: �> DISTRIBUTION BOX a. o e p' 24 PROPOSED :CHAMBER TRENCH �. 31" EXISTING. 1000 GALLON TANK TO. REMAIN 58 . 31' } BOTTOM OF SOIL PI EL. .61.:6 Tees shall.be constructed.of Schedule 40 PVC and. shall:extend a _ ., . NUM BER OF TRENCHES - ONE minimum of 6 .above the. flow.hne of the .septic tank and be on NUMBER OF UNITS THREE NO:GROUND. WATER .OR the centerline of. these tic tank located.directl under the PROPOSED LEACH TRENCH END VIEW P y PRECAST REINFORCED CONCRETE DISTRIBUTION BOX REDOXIMORPHIG FEATURES .OBSERVED clean--out. manhole Install on a lebel base The inlet pipe elevation shall be no less than 2 nor more than 3 wall thickness = 2" v elevation of the outlet pipe. Minimum above the. invert p p .. o _ 2» WITH. 31 INSTALLINCHES- OF DOUBLE EE 50Q `WASHED STONE . . » Minimum inside dimension 1 Septic tank shall have a minimum cover of 9 . SIDES AND 33 INCHES AT ENDS p Outlet inverts.shall .be equal to each other and at removable impermeable covers STRIPO.UT.NOTE: Two 20 manholes with.readily rem impe 2. minimum: below inlet invert, e material shall be rovided F&b.access ports; REMOVE ALL UNSUITABLE MATERIAL 5' AROUND_S.A.S; Of durabl _ m p P The distribution fines.from the distribution box. shall all ,. . e with as baffle. DOWN TO THE "C" LAYER AND REPLACE WITH GLEAN -The outlet tee. shall.-be. equipped g. . .. .._ equal inverts as determined by fiooding. the distribution box..to CMR. 15.255 (3) the hei fit.of the. distribution. line, invert, after all lines have .. g. GRANULAR' SAND.' PER- 310 been sealed: in place. Invert adjustments.shall be made b }illin with durable and nondeforrrlable material permanently fastened to. the. line or ZK OF jy reconstructing the. dines until all inverts are. of equal elevation. apt.. �Ss qey GHRIS?IP(E G GENERAL CONSTRUCTION NOTES FAiRNENY , 0 N 1. All the workmanship and materials shall .conform to D.E.P Title 5_ Na 926 and the Town of Barnstable rules and regulations for the subsurface g . disposal of se wage F� sT��' 2 Access ports over tank tees.shall be. accessible within 6 .of finish-grade. 3. . All components of the sanitary system. sha11 . be capable of _13.pg P a r,I:�, �n SHEET 2 OF 2 within 10 ft withstanding H-10: loading unless they are under or c�: l/ ,,,5 cn v F. Of drives or parking. . H-20 loadin shall be used under or within o. p g g g � � _ � © SEPTIC U.PG.R.AD�' PLAN 10 ft_ of drives. or parking unless noted.. Plastic equals. may be Q � s EPti=N N J. ® Prepared For- used in lieu of all .precast units. Dove. r 4. The excavator/con tractor shall call di safe and ..verfy the location =_7as Of all site utilities prior to any exca va tion, and shall be responsible ~°r s ��o? ®' �6 C'H UCKLE',S' WA Y for all matters relating to electric easements. ® q,�,o U ��y��,° In 5. Sewer i es shall be 4". Schedule. 40 PVC laid a t a min. 0.02 slope: p p. c. '�e . I 6. Any masonry. units used to bring covers to grade. be -�. c � Ma1'StOI1S 1�1115, MeaSSea c�l Ilse t tS mortared in lace: �° Design Da ta: , 7 ade shall have a minimum sloe of 0:02 ft er foot: Scale: 1 - 30 Date.• October 13; 2008 Finish gr. R. P. ExistingThree Bedrooms • 8. Existing system components -if any shall be abandonedPrepared By.- Three. Bedrooms 3 X 110 GPD - 330 GPD Required Flow per Title 5 requirements. Stephen J Doyle and Associates 9. The excavator/contractor shall be responsible to contact No Garbage Disposal Allowed 42 Canterbury Lane, E Falmouth, MA .02536 P Telephone: 508/540-,2534 Doyle Associates 2.4 hours prior to any required inspections. Ilse. Chamber Design 31'L x 10'W x 2" Eff/Depth 10.. All components shall be marked with magnetic tape: or R e . i �s-a �.Z o. c -1 [31 + 31 + 10 + 1OJx2.0 164sf comparable means in order to locate them. once buried. , 31 10' = 310. sf 11. 36 . max cover. .over system components 474. x 0.74 -. 350 GPD Total Design Flow NO. DATE � DESCRIPTION . . BY . .