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Home My WebLink About0057 EMERALD LANE - Health 57 EMERALD A = 046 039 1 f. _"_",s � �.�""' 1 II + i I i i I I it �� ~ �� • • � it4�r�1�N C. S. I Cape Septic Inspections Title 5 Inspections -_...N..` Alternative System Monitoring g 52 Rivers End Road Teaticket Ma. 02536 508-280-3356 septicinspectormike@aol.com Attached is a corrected Title 5 Report. We sent in a report for 55 Emerald Lane Martons Mills and that address does not exist. The correct address,is 57 Emerald Lane Martons Mills. This report is to replace the report sent prior. Sorry for the typo on prior one. If any questions please let us know. Thank you Mike Bisienere Cape Septic Inspections 508-280-3356 Y Commonwealth of Massachusetts b 'u - 039 Title 5 Official Inspection Form tiIa Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Emerald Lane Property Address Michael Ferraro Owner" Owner's Name informationis Martons Mills MA 02648 10/22/2020 required for every page. City/Town State Zip Code Date of Inspection r 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 6/* Iq 103 on the computer, use'oiily the tab Michael T Bisienere key to move your Name of Inspector cursor;do not Cape Septic Inspections use the return Company Name Key,., �u "`" 52 Rivers End Road �Pf IRba�' Company Address Teaticket Ma. 02536 City/Town State Zip Code G� 508-280-3356 S13938 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 usoe tel:; -r4 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 a `r 10/22/2020 Inspectors 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 9Y p the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the :.w•= 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. JA "'f5i".8oc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1'of 18 i Gi^ Commonwealth of Massachusetts Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Emerald Lane u- Property Address Michael Ferraro Owner Owner's Name �., •,< . information is rgq'Uetl for every Martons Mills MA 02648 10/22/2020 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: This 3 bedroom home has an H-10 1000 gallon septic tank with and an H-10 D-Box feeding a leaching trench 1 V X 25'X 2' with 4 infiltrators with stone. At the time of the inspection the-jeaching, was dry and no visible failure criteria was found. 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 nQ#c 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 Title 5 Official Inspection For 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityfrown 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,p'pe(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: f 1.rv.de.;ifs( _1 ❑ 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 MR 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 i Commonwealth of Massachusetts �v Title 5 Official Inspection Form t 1Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ~' u— 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water r ❑ 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. 5'jir:g:;;, , q: h„ ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet'oN 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,--- El ® 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 Title 5 Official Inspection Form _ I` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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 '/z day flow Wl 1� Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® obstructed pipe(s). Number of times pumped: ,-"E:Y.ii; ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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'ari'a`lysis'&his system passes if the well water analysis, performed at a DEP certified__ laboratory,for fecal coliform bacteria indicates absent and the,&esence of ammonia nitrogen and nitrate nitrogen is equal to or less tha'-`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. ❑ ® 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 wAh$aA., design flow of 10,000 gpd to 15,000 gpd. h._,e For large systems, you must indicate either"yes" or"no"to each of the following, in addition to thy`, 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'18Jr 1V(f X. /��,��..';y� Commonwealth of Massachusetts d 7 t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 57 Emerald Lane u� Property Address Michael Ferraro Owner Owner's Name information is .required for every Martons Mills MA 02648 10/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) y:, � to• l - ,:,.,;. r' If you have answered "yes" to any question in Section C.5 the system is considered a sigr4vantCE �) : s threat, or answered "yes" to any question in Section CA above the large system has failedhThe 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?,,, ; << _ -k. 4 El ® Have large volumes of water been introduced to the system recently or�asgpart 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? r ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of constructipn,r''y'r r..• dimensions, depth of liquid, depth of sludge and depth of scum? da of z' ; ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] �.. •M.F.; d<1 tip:Cs..'�: , t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .............� !% 57 Emerald Lane t,— Property Address t.; v r.z; Michael Ferraro .t.l° -`t' Owner" - Owner's Name t „ information is required for every Martons Mills MA 02648 10/22/2020 _ page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: I Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): GPD lias Description: re Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No Wk, If yes, discharges to irlt3iiss.7i:i'' Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes fir-No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gPd))� Detail: In 2019-19,000 gallons were used and in 2018-59,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: estimated May2019 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page Commonwealth of Massachusetts `- , ---- Title 5 Official Inspection Form xa . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments E, 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) :4 2. Commercial/Industrial Flow Conditions: - t 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? El Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ 'Yes ❑ No f, 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): z� ,, 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? (Reason for pumping: fl.a t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 14 Subsurface Sewage Disposal System Form Not for Voluntary ryAssessme nts 57 Emerald Lane u°- Property Address Michael Ferraro Owner_' Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. City,?own 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: New leaching 11/29/99 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): ., = Depth below grade: 1611 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): ^ Distance from private water supply well or suction line: town water feet 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 f r Commonwealth of Massachusetts t+F Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ``�� 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) _-_ 6. Septic Tank (locate on site plan): - 51, =� Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" 311 Scum thickness Distance from top of scum to top of outlet tee or baffle I ' Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. -31 t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I , Commonwealth of Massachusetts Title 5 Official Inspection Form lI b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 57 Emerald Lane U- Property Address Michael Ferraro - Owner. .: Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 ----- - page. CitylTown 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, structur6'I1'ntegrity, liquid levels as related to outlet invert, evidence of leakage, etc.): --- 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 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`0 Commonwealth of Massachusetts :. Title 5 Official Inspection Form11 - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is Martons Mills MA 02648 10/22/2020 required for every , page. CityTrown 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.): At the time of the inspection the liquid level was apx 1" below working level and there were-:no visible signs of solids carryover. It appears the loss of water due to no use. The D-Box appears to`be'- " ==' structurally sound. 'mY t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Emerald Lane Property Address Michael Ferraro "- Owner. '', Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 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-j:`'4`."}!`'' " I * If pumps or alarms are not in working order, system is a conditional pass. I 11. Soil Absorption 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: I � ® leaching trenches number, length: 11' x25' x2'w/4infiltrators Elleaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system I 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 -- 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is Martons Mills MA 02648 10/22/2020 required for every page. Cityj7own State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) 5- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the leaching was dry and no visible failure criteria was found. a�av .. "D y= 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): ^itic:1 of Number and coifiguration 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•A=ifi;�rl Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N' on t.. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments r u 57 Emerald Lane - - -- - Property Address Michael Ferraro Owner_ Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 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 ic.. „ Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: r Provide a view of the sewage disposal system, including ties to at least two permanent reference WElandmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply ester's the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - — iu. Q A l 131 :iL A3Q3� '.gip, t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Emerald Lane V Property Address Michael Ferraro Owner- = Owner's Name j 'information is required for every Martons Mills MA 02648 10/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ' ® Shallow wells Estimated depth to high ground water: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: r }(jisk5-. t ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. i � I Before filing this Inspection Report, please see Report Completeness Checklist on next page. 'mac"•t:�;i%: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts � ,�-p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. CityiTown 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 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate ��_4 Z. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ro ., �Ud Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • , 5,61 Emerald Lane _? roperty Address I ` Michael Ferraro Owner Owner's Name / information is required for every Martons Mills ✓ MA 02648 10/22/2020 page. Cityi7own. State Zip Code Date of Inspection . Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information frlling out forms on the computer, usg;only the tab Michael T Bisienere `key'to move your Name of Inspector cursor=do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Co � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 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 ;,R.. - - . ;-" 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 Ir4K;; 4. ❑ Fails r J-04.. 10/22/2020 I ector'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 "r in the future under the same or different conditions of use. !'`f$insp�doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane -- V� Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 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: C4 :- ® 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 _ `'.7i'' ` indicated below. Comments: This 3 bedroom home has an H-10 1000 gallon septic tank with and an H-10 D-Box feeding a leaching trench 11'X 25'X 2' with 4 infiltrators with stone. At the time of the inspection the leaching was dry and no visible failure criteria was found. t, 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 Cerfificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts �� Ih Title 5 Official Inspection Form <I1' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is Martons Mills MA 02648 10/22/2020 required for every page. Cityrrown 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. ❑ Observatior 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): n•n El The system required pumping more than 4 times a year due to broken or obstructeds ftel(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: to ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. �!% 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityi7own 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'br- `°if 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 j 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: y4• 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 Cit, c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form _ iIb Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. City,?own 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 El ® 1/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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 ari`a`lysi! [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. ❑ ® 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:45," 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-ie F a: Commonwealth of Massachusetts "f ``` �nJ iP Title 5 official Inspection Form +_ �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane u� Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 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? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. CityrTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 - - plus DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 330 GPD Description: i'1Y• Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( y 9 (gpd))� Detail: In 2019-19,000 gallons were used and in 2018-59,000 gallons were used f, Sump pump? ❑ Yes ® No Last date of occupancy: estimated May 2019 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 nP - I Commonwealth of Massachusetts Title 5 Official Inspection Form III' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is re quired for every Martons Mills MA 02648 10/22/2020 page. Cityrrown 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? ❑ Y-es--❑.: No If yes, discharges to: _ Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form I_ I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 55 Emerald Lane - .----- Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 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: New leaching 11/29/99 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 16"feet .Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp:cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <Iii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is req uired for every Martons Mills MA 02648 10/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - - 6. Septic Tank(locate on site plan): 5" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years III Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 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 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. II t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �� :, l? Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane -- Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 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 Ls ' Date of last pumping: Date - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural`integrity', liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons „ t Design Flow: gallons per day -- - - t5insp'doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of Commonwealth of Massachusetts ,;r.;.. :• �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 55 Emerald Lane V Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 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 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids caeryove'r, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was apx 1" below working level and there were no visible signs of solids carryover. It appears the loss of water due to no use. The D-Box appears to be structurally sound. ,y... t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - .IIn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane v- Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): I Pumps in working order: ❑ Yes ❑ No* G! 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 Absorption 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: 11' x 25'x 2'w/4 infiltrators ❑ 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityrrown 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.): At the time of the inspection the leaching was dry and no visible failure criteria was found. 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 c� Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V� 55 Emerald Lane -- _- Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (no-e condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5. Official Inspection Form p .. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: r 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 I . R a t A14 Ii i AL ::. A as a A3�a t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form <II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55'Emerald Lane u Property Address I Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water i - .. . -J ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of sepe ration. 7'a Before filing this Inspection Report, please see Report Completeness Checklist on next page. ci1v'1. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 ru+ •. Commonwealth of Massachusetts Title 5 Official Inspection Form <yI' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Emerald Lane Property Address Michael Ferraro Owner Owner's Name information is required for every Martons Mills MA 02648 10/22/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist :_ 4 ,w.,,)n 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 4 checked ® C. Inspection Summary: Ir7to ., 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 's t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ACCU SEPCHECK Title 5 Septic Inspection and Locating Service 5-7 W /fit /f 14 elf Y�'5 CERTIFIED JOE MARTINS � /P�f� S' r�f �,,/ f c' �Pv✓,,u�S� • �r 17 Northside Drive Cp U vr! dYt Gt n J I�P6b r^ YU t,�� 31�tG1►�Q �P' South Dennis, MA 02660 A� 508-385-5891 /" • Residential • Condominiums 9 Com rciai 0 y' COMMONWEALTH OF `MASSACHUSETTS EXECUTIVE-OFFICE OF E 4.MONMENTALL`AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 92-5500 rY. No �VEp 1 — TRUDY CORE of 6 19gg at secretary ARGEO PAUL CELLUCCI �0� B.STRUHS Governor 4 Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A 9 CERTIFICATION M �+ Property Address: 57 Emer-alG( Lgwe, Name of Ownw Ra/�/—4—n�� Marione �//1 L.MC(k larPj VATS MAAddressofOwner: 5--) 'Q►G( LanAe— Date of Inspection: //— 6— 7 9/�,�� / �y� - M Ar-s-fns /u I U,S A 4- 0 2��8 Name of Inspector:(Please PrinO jard 'p 7 ///¢f'rwj 1 am a DEP approved r, . �nspec:orpasuent to Section 15.340 of Title 5(310 CMR 15.000) �Company Nam vie: � Mailing Address: O S�Df�A�/!.f /�/� d Z1060 Telephone Number: r CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: v_ Passes _ Conditionally Passes _ Needs Further Evaluatio By the Local Approving Authority _ Fails 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 thirty(30)-days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Erivirotimental Protection. The original should,be senrtor" system owner•and copies sent to the buyer,if applicable,and the approving authority. . NOTES AND COMMENTS �2 r L/QU Z2Ve 901)'/14y Ovt d-( 74_ ,4uq//-44 J Zm e 4T 7o" . LPQirl p t T 0' .• f 1an /70 4Ae_ qwrce e X- klS ) )ee o4 A.— n //S cS•P/,� . revised 9/2/98 Pagel of11 `J Printed on Recycled Paper r SUBSURFA'CE-SEWAOE DISPOSAL SYSTEM INSPECTION FORM - CERT iRcA".'(continued) Property Address: Owner: 57 Emerald Lane,Marstons Mills MA Date of Inspection: Boynton November, 1�I9C, of AINSPECTION SUMMARY: Check A.- SYSTEM PASSES: [/ 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. /� COMMENTS: GPa o ya/7— Ari/� ��2" CG?oac!TX B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes, no,or not determined IY,N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspectioa.if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ 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 pumplog-inore than four timas.a,.yeardue to broken or obst. cted pipe(s). The system Will Fe. inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed revised 9/2/98 Page 2of11 s • ~ r N r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(condnt edl Property Address: 57 Emerald Lane,Marstons Mills MA Owner: Boynton Date of Inspection: November 6, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by oard of Health in order to determine if the system is failing to protect the.. public health,safety and the environment. 1) SYSTEMWILL PASS UNLESS BO F HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303,(1Hb)THAT THE SYSTEM IS NOT FUNCTIONING IN A r ER WHICKWILL.PRO]ECT THE PUBLIC HEALTH.AND SAFETY ANDLTHE EII[{OHONIMENL• Cesspool or vy is within 50 feet of surface water Cessp 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 WA PPUER,IF ANY)DElERIMES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH SAFETY AND THE ENVIRONMENT: - - _ The system has a septic tank and soil absorption sy m(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil abs on system and the SAS is within a Zone 1 of a public,water supply well. _ The system has a septic tank and soil a orption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and s absorption system and the SAS is less than 100 feet but 50 feet or more from a. private water supply well,unles well water analysis for coliform bacteria and volatile organic compounds indicates.that the well is free from pollution fr that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method us to determine distance (approximation not valid).- 3) OTHER revised 9,/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,A•. �.r CERTIFICATION.(continued) 57 Emerald Lane,Marston Mills MA Property Address: Boynton Owner: November 6, 1999 Date of Inspection: D. SYSTEM FAILS: You must indicate either"Yes" or "No" to each of the following: �(IQ 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of-sewage inwfacili"-9stem component*due!to an overloaded orciegged-SA&or^cesspo(A. _ _LX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. v Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ f_// Liquid depth in cesspool is less than 6" below invert or available volume is leis than 112 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. J.� Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for -coliform bacteria,volatile organic-compounds,ammonia nitrogen-and nitrate nitrogen. . - E LARGE SYSTEM FAILS: You must Indicate either"Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater rge System)and,the system is a significant threat to public health and safety and the environment because one or more of the owing conditions exist: . Yes No the system is within 400 feet of a s ce drinking water supply the system-le,within•200 •ofa�rtei"o-e �r PP1Y the system Is 1 d In a nitrogen sensitive area(Interim Wellhead Protection Area 4WPA)or a mapped Zone II of a public water suppl oil) The owner or operator any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Depa ant for further information. revised 9/2/98 Page 4of11 l x � Y S.UBS(MFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART e CHECKLIST Property Addrera: 57 Emerald Lane,Marstons Mills MA Owner: Boynton Dace of inspection: November 6, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. _✓ _ .None of the systemsompoments.Uw Aran pumped4or stJmmt t+wo-weeks-and dw'wystem ImAmma4eceieia940Mdllow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The 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. ✓ _ �xclvDiNb All system components,-exsivdhM"the Soi A'f bsorption System, have been located on the site. ✓_ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on-the site has been determined based on:- Existing information. For example, Plan at B.O.H. A/Q /0,91,0 f� Q�grfs Q/J T j/� _✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)1 The.facility owner-.(and-ocrirpants.if.cWaraW.from.-owner).,were,pfmdded,with infurraatiomon th-pmpar maintenmma"f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL.SYSTEM WSPECTION FORM ` PARL°C .. SYSTEIIA INFORMATION Property Address: Owner: 57 Emerald Lane,Marstons Mills MA Date of Inspection: Boynton November 6, 1999 FLOW coNOmonls RESIDENTIAL: Design flow:�/jQg.p.d./bedro Number of bedroomslesign):T F Number of bedrooms(actual): 3 Total DESIGN flow 3 0 Number of current residents: Garbage grinder(yes or no):_.,&jp Laundry.(separate system) (yes or no)-; if yes,separate impaction,rttquired R Laundry system inspected Ins or no) wa4e .S� eiw CQ �+tsa Seasonal uae(yes or no)- 0 ^� r Water meter readings,if available(last two year's usage(gpd): � � 2 q Sump Pump(yes or no).-NO Last date of occupancy: gnCG(/&it04 rI T�/000 c5 R y _ ��j�Q , > COMMERCIAL/INDUSTRIAL: (/!P Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank ent: (yes or no)_ Non-sanitary waste dis ed to the Title 5 system:(yes or no)_ Water meter rea ,if available: - Last date ccupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING REPPRDS and so4rce of infor ation: System pumped as part of i spection:(yes or no),_ a If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ` _Septic tank/distribution box/soil absorption system `zeQCA I r W Z f S f17w- \J Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous Inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date(nsWed44f-*nown)-end soumo,aUnfe matlon: Lam-- lG7 '7 Sewage odors detected whowarriving at the site:(yes or no) v . revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirmadl property Address: Owner: 57 Emerald Lane,Marstons Mills MA Daft of hupec6on: Boynton November 6, 1999 BUILDING SEWER: (Locate on site plan) //u � Dept below grade: Co Material of construction:_cast iron' 40 PVC_other(explain) Distance from private water supply well or suction line / �d q �f f� �,�/U Al- Diameter Comm : condition of joins venting,evidence of leakage,-etc.) SEPTIC TANK:_ J(locate on site plan) 2 1 d✓I let 1?14 Dept below grade,— Material of construction:_concrete_metal_Fberglass _Polyethylene_other(explain) if tank is metal,fist age_ Is_age_confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: jql, s ffl Distance from top of udge to bottom of outlet tee or bae: `_ Scum ce from t �// /e ��t IQ r/O � � 7 In Distance from top of scum to top of outlet tee or baffle: �/' ,/ V7 T{� /Q Distance from bottom of scum to bottom of outlet ee or baffle: How dimensions were determined:a -<17 S (/t;Ve, Comments: (recommendation for pumping,c ndition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, struct��egrity, evidence of leakage etc.) V GREASETRAP: VL��rl�y (locate on site plan) Dept below grade:_ 4 Material of construction:_concrete_metal_Fiberglass _Polyetylen _other(explain) Dimensions: Scum thickness: Distanct.from top of scum to top of outlet tee or b Distance from bottom of scum to bottom of tee Jrbaffle: Date of lest pumping: Comments: (recommendation for pumping, ndnion of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of-leakage,etc.) revised 9/2/98 Page 7ofII . SUBSURFACE SEWAGE DISPOSAL-SYS IEM INSPECTION FORMA SYSTEM INFORMATION(continued) L Property address: owner: 57 Emerald Lane,Marstons Mills MA Data of kopecti«r Boynton November 6, 1999 TIGHT OR HOLDING TANK- (Tank,must be pumped prior to, t time of, inspection) (locate on site plan) Depth below grade: Material of construction:_concrete_metal rglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gall /day Alarm p>of Alarm l Alarm in working order:Yes_ No_ Dater of umping: Comme (condtilet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on she plan) 7-,Q Y� Depth of liquid level above outlet invert:� n,e ' V O '0/S/ '`� Comments: (note-if level q9d di tributio is equal,evidence of olids car over, evidence f leakage into orCout of box etc. - - 70- PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,con on of pumps and appurtenances,etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE:OISPOSAL=SYSTEM INSPECTION.FORM PART;C SYSTEM INFORMATION(continued) Property Address: punier: 57 Emerald Lane,Marstons Mills MA Deft of kapection: Boynton November 6, 1999 SOIL ABSORPTION SYSTEM(SAS):— (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: � e -�j leaching.pits, number: � J 0/NQ 5 "I� Q� leaching chambers,number:_ f leaching galleries,number:_ r�u leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: J� (n a condition of so', signs of hydraulic failure,level of ponding, da soil, condition of vegetatio , etc.) n A D L L�acG� P/ 7- has CESSPOOLS: (locate on site plan) ®� �P �vlGr C`` O+rI("r zPl Number and configuration: Depth-top of liquid to inlet invert: L PCf l P`LPYP!. nve Depth of solids layer: 01 tj l^ 5'777/A L/d,P Depth of scum layer: Dimension's of cesspool: Materials of construction: Indication of ground r: inflow sspool must be pumped as part of inspection) Co ments: (note condition of soil,signs.of hydraulic failure,-level of ponding,-condition of-vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions.: Depth of solids: Comments: (note condition of soil,signs of hydraul' ilure,level of ponding,condition of vegetation;etc.) revised 9/2/95 Page 9of11 r a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM ONFORMATION(conhnueM Property Address: Ownw: 57 Emexald Lane,Marstons Mills MA Date of Irakneciion: Boynton November 6, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply com(s into house) Vv usA' %A O c O p LAN f-VIU revised 9/2/98 Page 10of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of hupection: 57 Emerald Lane,Marstons Mills MA Boynton November 6, 1999 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar N Shallow wells Estimated Depth to Groundwater_Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records ' /Checked local excavators, installers y Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) GrA Bd _ S 6/1 cp-s- 3 1tiC CUi►fUw�/1'► f ` `7o revised 9/2/98 Page 11ofIt \ j _ TOWN OF$ARNSTABLE S? Cry Qra f c� LOCATION h 4e-- SEWAGE # a `'_ VILLAGE 11461--12ia 5 G� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /t�y LEACHING FACILITY: (size) fnn NO. OF BEDROOMS BUILDER OR OWNER (+ PERMIT DATE: / / 7 ? COMPLIANCE DATE: r 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 feel of leaching facili ) Feet Furnished by S 6k' //l/S CGiLekC4'PG `/ _�9 IDMO C �• $c-22� l NUw� _ TOWN OF BARNSTABLE I� JCATION L;�G. !1'fl t C..yvi. SEWAGE TILLAGE /YI 1 t1� /�l_S ASSESSOR'S MAP &LOT ' INSTALLER'S NAME&.PHONE NO._ " ,L/a Ce4oQit S�t✓ C .-.SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i,,/ I�"Ol�r''�4tL.� (size) /s /� X 2-.� Xd NO.OF BEDROOMS BUI.DER OR OWNER a ` PERMTTDATE: I COMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 _ ` u /py 9 J f A I 13 f 1_ _ t 1. No. 7 CJ — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Disspozar *psstem Con!truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System �,ndividual Components Location Address or Lot No. 557�`►'t�v� Owner's Name,Address and Tel.No. PIA✓vtk �o�� Assessor's Map/Parcel0 t O -3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: ? Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3U gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 2Kc 3 r—�, LCO., S�� `.1 Type of S.A.S. Cli Description of Soil Nature of Repairs or Alterations(Answer when applicable) MCST04Ll -1L ®r Yrr r/Lt e✓ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance ha e y Signed I & Date Ad�T Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued TOWN OF BARNSTABLE LOCATION S-7 SEWAGE19-- VILLAGE /YI I /s1 ASSESSOR'S MAP &LOTK7� INSTALLER'S NAME&.PHONE NO. 411 g C 4 og f el 4 C SEPTIC TANK CAPACITY Id a a �— LEACHING FACILITY: 141�l r"Z-9, s' (size) (type) 'L NO.OF BEDROOMS BUILDER OR OWNER a C, PERMPTDATE: COMPLIANCE DATE: r Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 i Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ! � �T i i }f i ;. .4��e THE COMMONWE*M"OF MASSACHUSETTS Entered in computer: Yes "PUBLIC HEALTH DIVISION - OWN OF,BARNSTABLE, MASSACHUSETTS 01p�plication for Mig gar *pgtem CowAruction Permit Application for a Permit to Construct( ')Repair( )Upgrade( )Abandon( .) ❑Compleie S"ystem Individual Components Location Address or Lot No. 5-7 497ftwvc,_ • K.� Owner's Name,Address and Tel.No. Assessor's Map/Parcel ®=r —o , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: f Dwelling No.of Bedrooms . Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( )!Cafeteria { Other Fixtures Design Flow ::373(-) gallons per day,. Calculated daily flower gallons. Yn_ Plan Date Number of sheets Revision Date Title Size of Septic.Tank '2scc i b a �� .,J Type of S.A.S. r Cc� ye k K Description of Soil .. ''-_ 1 Nature of Repairs or Alterations(Answer when applicable) -T,64 t(!�! L z 1 . I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has Krealth. Signed Date Application Approved by / A Date Application Disapproved for the following reasons Permit No. Date Issued --------t ————————----- ——————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( � Abandoned( )by at Ulu `' f h bpeen constructed in accordance with the provisions of Tines`and the for Disposal System Construction Permit No. 7/ dated Installer ( Designer / The issuance of this p'rmit sha 1 not be bns ed as a guarantee that the y to will function deli ned. Date �. 1 Inspector .% P1e - 'o, ----------------------------Fee � /•-- {4 THE COMMONWEALTH OF MASSACHUSETTS Q L4 '� PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS Mi000af *potem Con!5truction Permit Permission is hereby granted to Construct( )Repair( ) pgr de((, Aba on )r(/ System located at c e </_ , and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her,duty to comply with Title 5 and the following local provisions or special conditions. , Provided:Construction must be completed within three years of the date of this permit. Date: Z Y Approved by C /Jr 1i6i99 1 NOTICE: This Form Is To Bel ed ForYthe Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH :•AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for dis posal works cons iuction permit signed by me dated `� a`�'-�1 concerning the property located at 64 Mu l�s meets all of the following criteria: L,e• The failed system is connected to a residential dwelling only. There are no commercial or business Zes associated with the dwelling. eTihe soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system ere are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the ma.-dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor ad when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surf/ace Elevation(using GIS information) B) G.W. Elevation Gr d ;the MAK High G.W. Adjustmentl+ DIFFERENCE BETWEEN A and B u SIGNED : , DATE.- [Sketch proposed plan of system on back]. q:hcalt:'t folder:cct i �� y ,,, a r l �/ O�� y .�,� em�� W-8 �� ti� .; ,_, •.SR.�r � _ �'k 0.-_ w f Ili�yl99 -D�t97 '� 27 - LOiCATION S SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME & ADDRESS B Ui-t R OR OWNER DATE PERMIT ISSUED HATE COMPLIANCE ISSUED 77 �� t No..*... --...... Fmic........f :.:D..�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _. .......---.OF..................................... .......... .............. ...... Appfiratiun -fur 430paviat Worko Touutrurtion Vrruift Application is hereby'made for a Permit to Construct (vo') or Repair ( ) an Individual Sewage/isposal System at: Location-Address or Lot No. c.OA/?--------------------- ----- 5 Owner Address Installer Address d Type of Building I,PC Size Lot...AA,,__M_.........Sq. feet U Dwelling—No. of Bedrooms-----3------------------------------------Expansion Attic ( ) Garbage Grinder (14D) a4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ____________________•----______-_. W Design Flow___--------S'.f�--------------------------gallons per person er day. Total daily flow.............7-P_n......................gallons. WSeptic Tank—Liquid capacity-I.P.Q----gallons Length____ __________ Width----S'.......... Diameter------- Depth.....5"...... x Disposal Trench—No- ____________________ Width-------------------- Total Length-------------------- Total leaching area-..._-__-___.-_____-sq. ft. Seepage Pit No........./_-__-_____ Diameter..........6........ Depth below inlet------6........... Total leaching ar ....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by----------------------------------------------------------- --- Date-_-.--.---.----------------.-------.---. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water._-_-_-._.___-__._-.-. (i Test Pit No. 2.....___.. minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------ I ------- -------------------------------------- ......................................................................................................•----- 0 Description of Soil------------------ -----------------------------•--------------- ------------ ------ VxC_r3 /rSc� S19 ...--.•?n------------``-----�-�------------------------------------ --------------------- ---- ----------------------------- W ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- UNature of Repairs a'r Alterations—Answer when applicable..........................................................--------.---------------------.-_----. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.......... ------------------------------------------------------- Date Application Approved By----- ° ----------------------------------------------------------•-•------•-------•- .............. I' 7 Date Application Disapproved for following reasons-------------------•--------__-------•--•-------••----------.---•-----•--------------•------ a•.............. -------------•--------------•-------•-••-----•---------------------•-------•-•------•-----------•----•-•---------------------------••-----•------------------------------------------------------------ Date PermitNo....... .q..-•-------•---•-•----•-•-•---•-...... Issued........................................................ Date w THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ..... _...............OF............................................. .......... Apphra#inn -for Diripaiittl Works Cnonstrur#ion Prruti# Application is hereby'made for a Permit to Construct (/) or Repair ( } an Individual •sewage„jDisposal System at: Location-Address or Lot No. /_ 11 0>'y t'� t.f L i`i` t.old. j AA.} _} _ Owner Address--•-------------------------------•---• --••-••--••--••-•--••-- •-••-._._.._........-----•----••-•••-••------ ---------- Installer Address UType of Building C f":' ` Size Lot_._-k_�./-_--______Sq. feet Dwelling—No. of Bedrooms_____ ____________________________________Expansion Attic ( ) Garbage Grinder QV o) aOther—Type of Building ............................ No. of persons..___-__--._____________-.-- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------- ----------------- -------------•---------------------------------•---------------_--•--- W Design Flow_____.__.__ .__________________________gallons per person per day. Total daily flow............. ¢_0--_.__-_____...._._._.gallons. Septic Tank—Liquid caacity-1f_0-----gallons Length----7.......... Width___�1._._-_... Diameter-----.>._.----- Depth.... ..--. xDisposal Trench—No....................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No........4----------- Diameter_________d___---__ Depth below inlet------ _........... Total leaching area.fof?!_0---__-_sq. it. Z Other Distribution box ( ) Dosing tank ( ), Percolation Test Results Performed by-------------------------------------------------------------------------- Date----_----------_-----------------------. Test Pit No. L__-------------minutes per inch Depth of Test Pit...----__--___-___-- Depth to ground water...-_-...-----..-_.-___- f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__._.-.______----_-__ t� ----------------------------------•---...--••--•----------._. ........................................................................................ ODescription of Soil-------------------------------------------------------------------------------- ---- ----------------------------------------------------------------------- v --------------------------•----- .....----• -D l..�3 C -----..a. '�e!.-------�......-..._._...'��--�= ----.................................................... W V Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------...______.__--___.. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI'of the State Sanitary Code:—.T,he,,tindersigned further agrees not to place the system in operation until a Certificate of tompltance T as:been issued by the board of.health. Signed--------- (= --''--'-------------•-------•--------•-----------------------•-••- r' Date Application Approved By....... --------------------------------------------•-------- --------------• A_/,i---7_1 Date Application Disapproved for .he following reasons------------------------------------------------------------- -----------------------•--•----Da.---------------- ..._..--••••--•----•••-•-••--••---•----•------•-••-------------------• .......................----....................................................... --------------------------------- ------------- Date PermitNo-------1.6-- ....................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i..........................................OF........................................ ........................................... err#i$ir #r >af 'IT mpliainrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----------------- .1 r ----------------------------- Installer has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descrihed in the application for Disposal Works Construction Permit No-------- ______________________ dated--------4f.--.A.J..-_....__.......•._.____..__ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE J Q ../ `, Inspector ---------------- THE COMMONWEALTH-,OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................................................................................... No.......A -•---• I FEE_: t�.,�1 _G)... Bi.spatittl Nork,5 Cn mi#rur#ion Errant Permission is hereby granted----------- N h1 to Construct (*-'I or Repair ( ) an Individual Sewage Disposal System at No...... ------i _� t-1.'._t •• z `T' ►► t ` '�1`'= - ------- Street as shown-on the application for Disposal Works Construction Permit No-14_4.-___..__. Dated------- ...... ----------••-•-••••-•-••-•••------- C _n --------------- Board of gealth DATE............................................................................... FORM 1255 HOBBS & WARREN. INC:. PUBLISHERS 1 ^{dra 3� 'FP ;a9ti o o'r�� c ^ara -y�fnq s k ^ "'� '- t �' �,. rr `a I c =t.,, r... 7 a F , 't ,Y =. 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