HomeMy WebLinkAbout0048 DEVON LANE - Health _ 48 Devon Lane, Marstons Mills
A= 057-002-003 Lot # 3
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� Commonwealth of Massachusetts / oum
; . Title 5 Official Inspection Form
,I1.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln +
1 Property Address
Wendy Wright `=
Owner Owner's Name r'
information is
required for every Marstons Mills MA 02648 4-11-19
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.
A. Inspector Information
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l 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 theproperty 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
4-11-19
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
il: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons,Mills MA 02648 4-11-19
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:
System is in good working order with no sign of failure.
2)'
System Conditionally Passes:
❑ One or more system components.as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
41 y,;3 Title 5 Official Inspection Form
hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
T, >" 48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
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
1 -,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
%I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
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 a Applicable toAII 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
3, Title 5 Official Inspection Form
IA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln _
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® 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
tributaryto a surface water supply.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 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.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
' ❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts f
,a Title 5 Official Inspection Form
r► Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
r U ,
e" 48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
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
❑ ® 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?
® ❑ Wasthe 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
if Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.r
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-2019
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
fay Title 5 Official Inspection Form
ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;> 48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
- Non-sanitarywaste discharged to the Title 5 system? Yes No
9 Y ❑ ❑
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner--pumped 2 yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
�1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
c�lf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>" 48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form ,
ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
i,
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
12"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
20"
1„
Scum thickness
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 15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition_, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� wa
N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln �
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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.):
8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
� gallons
Design Flow:
gallons per day
t5ins .doc•rev.7/26/2018 Title 5 Official Ins e p p chon Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
i r�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills ' MA 02648 4-11-19
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):
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.):
Good condition with water at working level and no sign of back-up from field.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorplion System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2-30'x4'x2'
❑ 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
p Title 5 Official Inspection Form
C,�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r: ,> 48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
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.):
Leach trenches in good working order with no sign of back-up into d-box or surrounding stone.
12. 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.):
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
i;l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
r� p Title 5 Official Inspection Form }
bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
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
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t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
f Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
� I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is Marstons Mills MA 02648 4-11-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
El Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet '
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
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
Commonwealth of Massachusetts
Il
Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r� rrr
48 Devon Ln
Property Address
Wendy Wright
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-11-19
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.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information-
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
4
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
TOWN OF BARNSTABLE
LOCATION t.,01_ P4 SEWAGE # 96 69
VILLAGE M+�(LSiarit M ��S ASSESSOR'S MAP 6t LOT
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INSTALLER'S NAME ra PHONE NO. HICXE;s 00,dS 7?/ y/zc
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NO. OF BEDROOMS _PRIVATE WELL O;i��� �AT�ER -
CJLDE*OR OWNER g_SSZ>j4c c:S C, Z\tf
DATE PERMIT ISSUED: Z'- 92
DATE COMPLIANCE ISSUED: " a� 17
VARIANCE GRANTED: Yes No
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LOCATION Ud17 ,3 pg-uaw► uwvE-. SEWAGE #
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VILLAGE M Siaw►S MAS ASSESSOR'S MAP & LOT `
003
INSTALLER'S NAME & PHONE NO. 14/eKE4, Oo/Jsr 7?/ V/z.(
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �(size) '30 Y --r,
NO. OF BEDROOMS P _PRIVATE WELL O ATER
ILDE OR OWNER
DATE PERMIT ISSUED: Z� 4
DATE COMPLIANCE ISSUED: " as-- 9�
VARIANCE GRANTED: Yes No
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No. �� FEE /60
THE COMMONWEALTH OF MASSACHUSItTTS yr
Barnstable , MASSACHUSETTS
�pyltirattivn for Visposal SVotent (gons#rurtion ferntit
Application is hereby made for a Permit to Construct(X) or Repair( ) an On-site Sewage Disposal System at:
Locatio A Vres&or Lnt No. Owner's Name,Address and Tel.No.
�o if3 Uevon Lane The Norman Trust
House #48 " Box 599, Mashpee, MA 02649
(508) 477-0023
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tgl.No.
'bon P@Ylt,t�_r Ferreira Associates
131 Spring Bars Rd. Falmouth, MA
(508) 540-3699
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinderr(o-)
Other Type of Building No, per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 55 gallons per day. Calculated daily flow 330 gallons.
Plan Date 1 0—1 0—9 6 Number of sheets 1 Revision Date
Title Sewage Disposal System Plan prepared for The Irene Trust
Description of Soil Test #1 : 0"-3 " "0 3 "-24 " "B" sandq loam, 24 "-126 " "C"
sand. Test #2: 0"-3 " 11011, 3 "-24 ", 24 "-120 " "C" sand. No groundwater.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has be n issued by thi oa f Health.
Signed _ Date
Application Approved b
PP PP Y
fl
Application Disapproved for the following reasons
`"2 AllPermit No. �� �d Date Issued !�
_ •1c..^ww'y'" 'V =14-��_n,. ,/ 4 e�- r+ f .�., /i :.. . r.... .,r...�..;�.i,--. ."..''""r"'+r1.^1+d.••"n"`M'N's wF+i�.^N«r••i y,.^i'.w�+r.-..-�a:..r.�,- -----r ..'.';...
No. -�� '1 5 FEE
THE rrOMMONWEALT�OF MASSACHUSETTS67
W
Barnstable e� MAS$ACHUSETTS_
c jayllra non for Pispooa' l 51 s#ezrt Chun #rnc t� Permit
Application is hereby made for a Permit to Construct (X) or Repair( ')an On-site Sewage Disposal System at:
Locatio A dres L No. "Owner's Name,Address and Tel.No.
�o` �` �fevon Lane ' IY1 {M T?�e Norman Trust
House_ #4 8 " .#, ff - `Box'59901- Ma.shpee, MA 02649
(508_-)' 877-0023
Installer's Name,Address,and Tel.No. <`` 'D 1 ner's N e,Add ess and T No.
f�ec-h�r,,f ,, rre "'ra Associates
131 Spring Bars Rd. Falmouth, MA
(508) . 540-3699 `
Type of Building:
_3 _ ._..
Dwell ng___.No of Bedrpoms - -a :t Garbage-Gr-inder(
Other. Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures '
Design Flow 55 gallons per day. Calculated daily flow 3 3 0 gallons.
Plan Date 1 0—10—9 6 Number of sheets I Revision Date
Title Sewage .Disposal, System 'Plan prepared for 2!bh Irene Trust
Description of Soil .Test. #I : 0"-89 110", 3"-24" "B" .sandy loam, 24"—'126"
sand. Test' #2: 0"-3" 0000,' 3 "-24", 24"-12.0" "C sand.'. No groundwater.
Nature of Repairs or Alterations(Answer when applicable)
Daie last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has be n issued by thi pard,.ol Hea
Signed ,De /e2��9pT
Application Approved bey' V' uF' Date
Application Disapproved for the following reasons
Permit No. 7& �d 9 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
1f1 S 6 gl e .MASSACHUSETTS
C1er#tfira to of C�omytiante
THIS IS TO CER-T-IfY, that the'On-site.Sewage Disposal System installed( or repaired/replaced( ) on
,t by. . -e ��l for
at _ Cyr' 44, ( -, , :
144- 5, 1 �'l e �SGben Ts�r�ucted in
accordance ith the pro y.isions of Title 5 and the for Disposal System Construction Permit No. .:> dated
)� 10I " 9 L Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.This
Certificate expires do
DATE 02 �-
Inspector
3
THE COMMONWEALTH OF MASSACHUSETTS t
No. `�" ,� `1� �� , MASSACHUSETTS FEE
Permission is by granted to
to construct( or re air( ) an On-site Sewage System located at '- U(114
W1 a�S-�eA,�ti
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within
nn-three years of the date below.
DATE R ,i' Approved b '
FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA
AREA PLAN
SCALE: 1 "= 40 • S YS TEM PROFILE d
FINISH GRADE NOT TO SCALE
SOIL EVAL UA TIONS
APPLICATION NO. P—B701 'T r,.
•.•,••• - ��� FINISH GRADE �- 2f� FINISH GRADE
JUME 4, 1996 OVER TANK OVER TRENCHES dog-U
EDWARD BARRY ad
TOW OF BARNSTABLE TOP FND .:' !% ir, J r /' � ;� q <.� i //^` \ i
7 TEST 2 /
• *___—_TEsr ___ -------, o• SCH 40 PVC
_ OR
y. at 8• :•y : I t CAST IRON TEES oCo Goo eopoo
7 o o. 'S
' re. ' �., y'Z. 1� '� ^ Via'.: ;►'.• i.i 00 n°i p. c°vOv°, •p° °,
• o 00 •..
g e '' 4. ° o 0 0.° 4CAP ENDS
• y BSM'T FLR i !� �. GG.'fC5 0 0°.° . vo °
y c:^ EQUALIZERS! o° •` °o 00 e 0 o a °o T QEL Eo o0
SANDY LOAM t _'_<) GAL. ° °oa° °° c °SANDY LOAM + .•.'� '•• CC
!oYA 5/6 !'O YH 5/6 4+ '.CJ v v o ° o o. 0•°o o•o Y . •
�'.�.; REINFORCED v' SA DIST.SOX 'ac°`o°Q o0 0': 0
CONCRETE o ° 0 .o ° C.G.2 U o°
o
24• { ,_::._ __.,..__.w.: _ _. _ ._ 24• iBAFFLE O°c Qo°o ° .i °•
y ... i j .',.'�...♦ ,... ..,..• 'f.a �.... ..► , v0 O 00 0 0 .01
c OOC�v• i•v. -
' ' - TO BE INSTALLED ON A °°o° o o c,° ° ° °° S o° ° °•• ••%°°°
'c• c LEVEL STABLE 'BASE °°000° °o ° o° °• °.°oo°'°:e:°°•
SANG
2.5Y 6/4
SAND , 2.5Y 614 SEPTIC TANK . 4
., TRENCH L ENGTH
.126. i_, ...-.,.__�. _.._. ___-___ ___ !2o• TO BE INSTALLED ON A 30 '
LEVEL STABLE BASE
NO GROUNDWATER 4'MIN.HEIGHT
lPEac•° AT 60• - 2`'r"/r"' NO TE.' DO NO T RUN HEA V Y EQUIPMEN T O VER S YS TEM ABOVE OBSERVED I
GROUND NA TER
2$ L EA CHING TRENCH SEC TION
NOT TO SCALE SOIL AND PERCOL A TION DA TA
LINE BEARING DISTANCE •a'w FOR FINISH GRADE
1 S 14'05'55E 19.69 SEE SYSTEM PROFILE APPLICATION Nli4, P-8701
PERC. RA TE >5 HINIrN
�S 12"MIN. TAA� FERR"rR
WI TNESSED B Y _EQW�RD BAMy
y'�P MIN.2" — 1/8"-1/2" DATE �&M It 1296
4"DIA.PIPE TEST P'T ELEV SB,7
'( WA SHED S TONE
TEST PIT ELEV. 69.2 a�
0V� •Q0 (—_NATURAL SOIL-- 2'MA X . EFFECTIVE
'QlS' •11 DO DEPTH
l� 1 290• -2- L 0' NOTES,
3/4"-1 1/2
WA SHED S TONE
MIN.- 3x 1 ELEVATIONS BASED ON M.S.L.
EXCA VA TED SIDEWA L L EFFEC Ts 'ID TH 2. TOWN WA TER ON SITE
`p 4' + 0 OR DEPTH 3. FLOOD ZONE 'C'
4. GROUNDWA TER ELEVATION 20.7 ---
_. _ ®� EFFECTIVE WIDTH FROM MONITOR WELLS
1 NUMBER OF TRENCHES 2
LOT 3 t
: 45, 702 SF,
x } m h
^ ° DESIGN DA TA
272 S. F. SIDEWA L L A REA . 74 GALS/SF 201 GALS. No.of BEDROOMS B
DIS` 240 S. F. BOTTOM AREA 74 GALS/SF 176 GALS. EST. TOAL n�0
EST. TOTAL DAILY EFFLUENT 330 GALS.
SEPTIC TANK 1500 GAL.
��ePG y 512 S. F. TOTAL AREA 379 GALS. - _
5
�JS
ti GENERA L NO TES
- -----5�------.� NOTE.'
1 ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
�- A CCORDANCE WITH TITLE 5 OF THE S TA TE SANITARY CODE
EXCA VA TE TO ELEV C4•0-oR LOWER AS REQUIRED
TO REMOVE ALL LOAM AND CLAY CONTAINING DATED MARCH 1995 AND ANY LOCAL RULES APPLICABLE
MATERIAL BENEATH THE LEACHING AREA.REPLACE 2. ANY CHANGE IN THIS PLAN MUST BE APPROVED
s e EXCA VA TED MA TERIAL WI TH CL EAN. CL A Y FREE GRA VEL BY THE BOARD OF HEAL TH
MECHANICALL Y COMPACTED IN PLACE
J a N/ •t _. 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BA CKFIL L ING
°; NOTIFY BOARD OF HEAL TH FOR INSPECTION
4. FND. EL EV V. MUS T BE CHECKED WHEN COMPL ETED
LEGEND 5. < THESE ELEV. MUST NOT BE CHANGED WITHOUT
�]rE l800 BAL
SEPTIC TAW I t THE BOARD OF HEALTH APPROVAL
6. BOARD OF HEALTH INSPECTION REO 'D WHEN EXCA VA TED
3
LEACa4ED !� � s - G8 - - EXIST.GROUND ELEV.
• LEAOXTlwffi TRENC►iEs r, `
u¢ SO-LOA49. 4'JVlM 2-DEEP
(SEE~ZL E7 2. ` -
0 8 _ •t,� FINISH GROUND ELEV.UNDERLINED
,15 , oo SEWAGE DISPOSAL S YS TEM PLAN f
PIPE INVERT ELEV.
P LAl1�E PREPARED FOR
TEST PIT LOCATION 4
`gRA
0.00 , . = o o SEPTIC TANK THE SRENE TRUST
c I
o DISTRIBUTION BOX LOT 3 DEVON LANE
¢ �/
{
4 c.I.oR SCH 4o P c BA RN$TA BL E MA,'SS.
4"BIT.FIBER PIPE-TIGHT ✓DINTS
• r,v 9%s
_ — PROPERTY LINES m DESIGNED : SAP DATE OCT09ER 10. 1996
FERREIRA ASSOCIA TES
MrN.CODE DISTANCE 131 SPRING BARS ROAD DRAWN : W SCALE.•AS SHOM,N
57 2 3 3 48 i
FALMOUTH MASS. i
MAP SEC PCL LOT HSE ®� CHECKED : COS DRAWING NO.• 101096 1�
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