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HomeMy WebLinkAbout0379 FLINT STREET - Health 3 '9`FI i nt Street :Marstons 'Mills 101 059061 i oal c Commonwealth of Massachusetts - Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C vv 379 Flint Street Property Address : Carol Hedlund Owner Owner's Name / Information Is Marston Mills V MA 02648 9-24-18 required for every per, City/Town State Zip Code Date of Inspection 'A 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. `voki nuuurrrl7n,, Important:When filling out forms A. Inspector Information 51—ff f33S-y ��:'' ' .•Cy on the computer, o: G use only the tab James D.Sears ?g: JAMES key to move your Name of Inspector 5 v: cursor-do not '�t: V' use the return Ca ewide Enterprises •- C, key. Company Name �� l� •. T1F ,.•"�o-SN• 153 Commercial Street Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails t 9-24-18 pector'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. l5insp.doc rev.7126!2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i, abed xed dH 90:9 6 81,0Z 1,0 100 Commonwealth of Massachusetts Title 5 Official Inspection Form h. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S� 379 Flint Street Property Address Carol Hedlund Owner Owner's Name Information is required for every Marston Mills MA 02648 9-24-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal.Tank D Box and three chamber's 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.tloc•rev.712&2018 Title 5 Official Inspeeiion Form:Suburface Sewage Disposal System-Page 2 of 18 Z a5ed YPJ dH 90:91. 81.0Z 1.0 100 Commonwealth of Massachusetts iN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 page. City/rown 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: 15insp.doc•ray,712612018 Title 5 official inspection Forth:Subsurface sewage Disposal System•Page 3 of 18 ` 8 abed xed dH 80:91• 81.0Z 60 1:)0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 Paw. Clty/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or pond ing of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5lnsp.Wc rev.7/2 512 0 1 8 Title 5 Official nspection Form:Subsurface Sewage Disposal System•Page 4 of 18 t, a5ed xeJ dH 20:56 260Z 1.0 100 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 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 MMIMN is less than 6° below invert or available volume is less than '/z day flow 4 EA Olt)1v4 ❑ ® 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 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. ❑ ® The system Lah. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 indicale 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 I I of a public water supply well t5insp.doc•rev.7126120le Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 18 5 a5ed xed dH 80:56 81.0Z 1.0 130 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form . Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Cwner's Name information is required for every Marston Mills MA 02648 9-24-18 POW. CityrTown 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 aff 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 NIA) ® ❑ 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)] 15nsp.doc•rev.7/2612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal system•Page 6 of 18 9 a5ed xe j dH 80:9 6 8 60Z 60 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 Page, CKy/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: NA 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Is Water meter readings, if available(last 2 years usage(gpd)): 2016-32,000Ga 2017-8,000 Gas Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date 15insp.doc•rev.W26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 L al5ed xeJ dH 60:91, 2 ME 1,0 1)0 I c Commonwealth of Massachusetts Title 5 Official Inspection Form Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 page. CityJTown 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-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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Wnsp.Wc-rev.TM1201a title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 8 of 18 9 a5ed xed dH 60:91, 21,02 1.0 130 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Flint Street L Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 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: 2004 Permit # 2004- 500. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3' 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.): Pipeing is 4" PVC SCH - 40. t5insp.doc-rev.712612018 Tltle 5 OMcfal Inspection form:Subsurface Sewage Disposal System•Page 9 of 18 6 a6ed xe� did 0 91• 8602 1,0 PO Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Qwner's Name information is required for every Marston Mills MA 02648 9-24-18 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 6, Septic Tank(locate on site plan): 26" Depth below grade:p g 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: 1500 Gal, Precast H-10 Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 29" 11 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Plan-Tape 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.): Tank at working level. Tank at 26"below grade wlboth cover's at 1'. Two inlet tee's and outlet tee. No sign of leakage or over loading. t5insp.doc•rev.V26WII Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 18 01, abed xed dH 01:91, 8 60Z 1.0 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 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 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 15insp.doc•rev.7/26/2018 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 6 6 abed xe� dH 0 91• R 60Z 60 100 4t"'\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments L 379 Flint Street Property Address Carol Hedlund Owner Ownees Name information is required for every Marston Mills MA 02648 9-24-1 B page. City/Town Slate 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.): D Box is 16"x16"-32" below grade w/three line's out. Cover at 1'. Box is clean and solid w/no sign of over loading or solid carry over. mnsp.doc-rev.708/2 A Title 5 Official Inspection Form:Subsurface Sewage Dlsposal System•Page 12 of 18 Zi, a5ed xeJ dH W91, 860E 60 100 !�f\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is Marston Mills MA 02648 9-24-18 required for every page. City(Town state Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc): 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: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: t5ursp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Dlspcsel System•Page 13 of 118 El, abed xe� dH 6 l:S 1 8lOZ 60 1:)0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Flint Sheet `J Property Address Carol Hedlund Owner Owners Name information is required for every Marston Mills MA 02648 9-24-18 page. City/Town State Zip Cade Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is three 500 Gal. dry well chamber's w/4' stone. Chamber's at 38" below grade w/cover at 18 Wet bottom. Wall's clean like new. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration top Depth— of DeP liquid to inlet invert q 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.V2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 a6ed xe b 6 zI dH WS l• 21,02 60 130 Commonwealth of Massachusetts U � Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 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 (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp,doc-rev.T126M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 5l, abed xed dH 6 6:9 6 91,2 1.0 130 Commonwealth of Massachusetts Title 5 Official Inspection Form ` T Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is Marston Mills MA 02648 9-24-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks, Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately -� - 4&' Ara= 4a o e3- 3= 56 8 Mnsp.doc•rev.7,12K018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 gl, abed xed dH W91• 860Z 60 PO Commonwealth of Massachusetts Titles Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is required for every Marston Mills MA 02648 9-24-18 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N° 10, Estimated depth to VWground water: 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: 12-31-03 Date ❑ Observed site (abutting propertylobservation 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: T.H. on Design plan 12-31-03 10' no G.W.. Bottom of chamber's at 5"-8" below grade. Bottom of chamber's at 4'-4"above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7ri6/2018 Title 5 Otficial Inspeciion Forth:Subsurface Sewage Disposal System-Page 17 of 18 a13ed xeJ dH Z 6 l ME 1.0 100 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments kllp�r; 379 Flint Street Property Address Carol Hedlund Owner Owner's Name information is Marston Mills MA 0264E 9-24-18 required for every page. CitylTown 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 (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 an pg, 16 or attached For 15: Explanation of estimated depth to high groundwater included teoj>rof AC 14 I5nsp,doc-rev.7012018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 18 of 18 9 abed xed dH U91, 81.02 1.0 130 i TOWN OF BARNSTABLE LOCATION ��«7 5-` th. /,J, //S SEWAGE # 4X)I-I cod n�� 1 - 6:i�j 00 i J VILLAGE&A6 ZA15 w.115 ASSESSOR'S MAP& LOT Of INSTALLER'S NAME&PHONE NO.SLS�Qi C ✓J�'ny� 7�e SEPTIC TANK CAPACITY 1 SOO 5 el l 4/d^) LEACHING FACILITY: (type) (size) ra 3 3 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: oZ' y Lf COMPLIANCE DATE:. Zile Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Era. (33 3,4 �S� No. 90 Fee ` 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 3pphratton for ;Dtgpogal *pgtem .Con!6tructton-permit r Application fora Permit to Construct( )Repair( )UpgradeAbandon( " ) O Complete System -.E'Individual Components Location Address or Lot No. a� ���^ S Owner's Name,Address and Tel.No. Cameo eduvnd- Assessor's Map/Parcel mQ��' u'S 19 (a C9 C0-0,k �- k i�r ter+ Ot46G Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel No. �5TbeC €rCLI'a�/"ReJ �rlg`�C?�J�✓� (.V�/� S -g`w)-90L6q 1a C osa e� 503-44 253-5 o b Aan cJ I c 14 Type of Building: Dwelling No.of Bedrooms 9— Lot Size�a65 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow L.)9 0 gallons per day. Calculated daily flow bS. gallons. Plan Date (31 Number of sheets 9 Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi o eal Signed 12, Date Application.Approved by ��+ Date �IT1 Application Disapproved for the WIlowing reasons Permit No. ���L/-��d Date Issued '�Pl —-2 �''7 1 . Y 4 t i f No.� 5Uv ..� .'t a � . . Fee /(JL X= - �+ Entered in com uter: L THE COMMONWEALTH OF MASSACHUSETTS p .4, 1 ; Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZLppftcation for �Dtgpogaf *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. I' Ca r, 14,?a icl Assessor'sMap/Parcel z.�„tauTr��• . NmAddress and Tel No.'Installer's Name Addss;and TelNo7 ens e, " �n9r�cQh. ~ RCc E q e - 0,)a 3-ci3©o O(jIc 14 l�Yc,Os cl.--<C. M 0 Type of Building: ` Dwelling No.of Bedrooms LI Lot Size 69/ a sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow L)y y gallons per day. Calculated daily flow bS gallons. Plan Date Cl I ( Number of sheets a Revision Date Title s Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) ' Date last inspected: t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi .Boar`d of ea Signedb Date Application Approved by•, �e' r �� Date e7—21 a Y Application Disapprovedrfor�the Vollowing r asons e Permit No. `S7 d Date Issued 21 a`7 ti THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS certificate of (Eompliance THIS IS TO C7� TI1;Y,that the On-site Sewage Disposal System Constructed( � ) Repaired )Upgraded ( ) Abandoned( ) y re at 3 7"1 Pt, 4 J , "• M 1 I f has been constructed in accordance with the provisions of Title'5 and the for Disposal System Construction Permit No. °')Ud Y--9V dated 0--d l—&'-1 Installer Designer The issuance of this pe it shall not be construed as a guarantee that the s ste will action as si tied. f Date a 1 U� Inspector No. 900 V^ ✓U Fee/Uy THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogaf *pgtem Congtruction Permit Permission is hereby granted to Constru t( )Repair K)Upgrade( )Abandon( ) System located at 3 7 el,n C I�+. ✓� �/ S _ 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/m st be completed within three years of the date o�tztw. Date: ! 1� Approved by /� V w i 9116/03 Notice: This Form Is To Be Used For the Repair Of Foiled Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM ow I, -QJ 0 V,hereby certify that the engineered plan signed by me dated concerning the property located at meets adl of the. following criteria: • This failed system is connected to a residential dwelling only. There are no comrnerc'iatw-- business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • 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 be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.EIevation +adjustment for high G.W. _ DIFFERENCE BETWEEN A and B DATE: 6 — NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. q:fttic�mvexemp.doc TOWN OF BAR/NSTABLE LOCATION A,19 r/ram i 1h• SEWAGE # -cod VILLAGES ��/S ��,�l S ASSESSOR'S MAP & LOT a INSTALLER'S NAME&PHONE NO:: / g�% L ' VyA) r�� + SEPTIC TANK CAPACITY pSOO LEACHING FACILITY: (type) 3 (size) NO. OF BEDROOMS BUILDER OR OWNER It/ PERMIT DATE: s v L( COMPLIANCE DATE: 2_ 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 Feet within 300 feet of leaching facility) Furnished by Lew� Pt l3a= �t5 Town of Barnstable Regulatory Services Thomas F. Geiler,Director * BARNSTABLE, MASS- Public Health Division s63.9• �� Thomas McKean,Director 200 Main Street,Hyannis,MA.02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 23 Designer: 't Installer: `1 Zse_- Address: 12 W. C✓v Address: 'SS , r,�. /oZ� ttw<a �-CU'� c v.,4¢ co 6e-j(1 On was issV ed a pen-nit to install a (date) (installer) septic system at 37 q Fi+rt}" S* based on a design drawn by ?�W t. fA(_ T�,\,,, (address) �r A.A e �0C"' dated designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. er's Signature) ����SN oF�,ss1c+ PETER T. MCENTEE CIVIL to (Designer's Signature) (Affix ere) sk PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH D ON. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form i I _ tg �.............. &ow � a�is ��m.�uk� ,lP�/Ma9Y! TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS VA wr, ASSESSORS MAP NO. PARCEL NO. —00 G#q7 ?DRESS: 37q Fit /7kArs-h3rlS VILLAGE: NAME'..... ®ceY CONTACT PERSON PHONE NUMBER LOCATION OF TANKS: f- CAPACITY: TYPE OF FUEL AGE: ? TYPE: LEAK U OR CHEMICAL: DETECTION S SYSTEM' U No DATE OF PURCHASE OF. EACH: 1 n�i'lu1NY`� - � S00 2. 3. 4. 5. DATE.OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. p TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS ASSESSORS MAP N0. PARCEL NO.�r9f v� �� ADDRESS I&Z_ VILLAGE/1%J'� /dam Ae/l1, fWeU. O� NAME; CONTACT PE'_SON f�' PHONE NUMBER LOCATION OF TANKS:. CAPACITY: ..TYPE OF FUEL AGE: TYPE: LEAK OR CHEMICAL: DETECTION SYSTEM! VA DATE OF PURCHASE OF. EACH: 1. 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT:-:Z7-Z)o f /11/j"r; ,U/( MAle dfJ/ TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON- THE BACK OF THIS CARD. �� � �� Fra►.�Ir . CENTERVILLE - OSTERVILLE FIRE DEPARTMENT l PERMIT FOR STORAGE OF FUEL OIL,�, In accordance with provisions of Chapter 148, G. L., and Regulations made under Authority thereof. Name .OB18.21.....C.QIIS.t.T..t1C.tjAla:: Cf�Name .....Alton,...F........And.e.rs.Q' n k 5 (owner or occupant) F (Installer) Address Gristmill Path,.....K.I�_�gcldress7S...Pleasant St. 9 1 ..................r�pann Burner Storage Make, .... a.YIIe.............. a ;, T e of Tank ,,,,Round Steel .. yp ............................................... Manufacturertf�s4'.yt .:.. Qm...:`: .Q,IiP.{apacity.... . ..:.....ga(s.(or) Size......:..........,.. Model No. or Size ..O�t A-.�? " ' .......Location ...UIId.6T.grOlilld ............................................ ..... Type ....C? .................. Mass. Ap roval No. .......... .:...... Permitissued .......... .rj..`.`., .. ....:....:........................ ............................... .................................................... ! . (Head of ire Department) ...................................................................................................... By .................................................................................,...:. _ (THIS PERMIT MUST BE CONSPICUOUSLY POSTED UPON THE PREMISES). NOTE: TO PREVENT'BREAKOUT, THE PROPOSED i TO OF FOUNDATION F.G. EL: 101.6t FINISH GRADE SHALL NOT BE < EL:98.3 EL:103.1 FOR A DISTANCE OF 15' AROUND THE F.G. EL: 102t F.G. EL: 101.6t /- F.G. EL: 101.6t MAINTAIN 2% MIN SLOPE OVER S.A, S. PERIMETER OF THE S.A.S. MAX. COVER OVER S.A.S. = 36" 36" MAX. COVER INSTALL RISERS OVER INLET & OUTLET ,3-50 GALLON LEACHING CHAMBERS IN SERIES INSTALL RISER OVER CHAMBER/S TO WITHIN 6" OF FINISH GRADE (WHEN REQUIRED) WITH 4' STONE ALL SIDES SHOWN ON PLAN AND SET COVER/S WITHIN 6" OF FINISH GRADE L =VARIES 40 PVC DOUBLE 2" ' oSHALLiT PIPES swn 3' LAYER OF L =7 4" SCH 40 PVC 6E SET LEVEL OVER L —1 (MAX.) 2/s' -1 4" SCH 40 PVC rRST 2 FEET 4" SCH WASHED STONE o i a, S= 27.(MIN.) 10 d S= 1% (MIN.) 7k:z a' PROPOSED 14 ® S= 1% (MIN.)) Erw EL'TIVE p�E3� I� DEPTH-2'' aim a'. 1500 GALLON INV. ELEV:=9$,10 INV. ELEV,=97.93 SEPTIC TANK 4' S.2' 4' 3/4"-1 1/2" INV.ELEV.=98:50 , . „ , - INV. ELEV.=98.25 I EFFECTIVE WIDTH 13.2' DOUBLE WASHED STONE INSTALL INLET & OUTLET TEES INV. ELEV:=97.80 TIE IN TO EXISTING GAS BAFFLE TO BE INSTALLED ON SEWER OUTLETS WITH OUTLET TEE AS MANUFACTURED BY TOP CONC. ELEV.=98.6 ---BREAKOUT ELEV.=96.3 4" SCH 40 PVC PIPE TUF—TITE, ZABEL, OR EQUAL INVERT ELEV.-97.80 ®�®� SEPTIC TANK & D—BOX SHALL BE SET LEVEL AND TRUE TO ® E3 GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED Ma®, —0 mom STONE BASE, AS SPECIFIED IN 310 GMR 15.221(2). BOTTOM ELEV.=95.80 4' 3 x 8.5' = 25,5' 4' 5' MIN, ABOVE BOTTOM OF EFFECTIVE LENGTH - 33.5' SEPTIC SYSTEM PROFILE T.P. EXCAVATION OR G.W. LEACHING SYSTEM SECTION o� PETER T. y's BOTTOM OF TEST HOLE EL,=90.8 N.T.S. MC W v CIVIL N.T.S. CIVIL (3) 5" DIA.OUTLETS No. 35109 11�—5.5 Imo- s--.�')�2„ DESIGN CRITERIA Fss/0%���'`" 1s g" r; 6„ NUMBER OF BEDROOMS: 4 BEDROOMS 41�� 10' SOIL TYPE: CLASS I AIL ('�� 2„ DESIGN PERCOLATION RATE: <2 MIN./IN. N.i.S Q—13OX 3 - 20" Dia• Covers DATE; DECEMpER 31, 2003 DAILY FLOW: 440 G.P.D. N.T.9. SOIL EVALUATOR; PETER T. MCENTEE P.E. DESIGN FLOW: 440 G,P,D, �- INSPECTOR: NOT REQ'D-CLASS 1 SOILS GARBAGE GRINDER: NO Elev. 'I'P Depth LEACHING AREA REQUIRED: (440) = 594.6 S.F. 100.8 0" .74 _ A SANDY LOAM SEPTIC TANK REQUIRED: 1500 GALLON 100.1 10YR 3/3 8„ USE 3-500 GALLON LEACHING CHAMBERS IN SERIES ®®®® ® �®�� Top View g ®®®®®®®®®®� 33" SANDY LOAM INVERT ®®®1®®E3 E3 E3 E3 E3 E3 10YR 5/8 24" ®10E@E3®®®E3�'1® 4" Dia. Inlets, 4" 4" Dia: Outlets 98.1 32" SIDEWALL AREA: 2(13.2' + 33.5') X 2 = 186.8 S.F. . • . ... ., roe" � ,� Q BOTTOM AREA: 13.2' x 33.5' = 442.2 S,F. TOTAL AREA: 629.0 S.F. 4" KNOCKOUT MED. TO COARSE DESIGN FLOW PROVIDED: 0.74(629.0) = 465.5 G.P.D. 20 DiiA. COVER 5'-8" 4'-7' 48" Liquid Level 4'-4" SAND 4„ 3„ 4" KNOCKOUT �/ 4" KNOCKOUT 62'� r 2.5Y 6/6 -► } SEPTIC SYSTEM REPAIR UPGRADE 4' KNOCKaur 90.8 120" 379 FLINT STREET, MARSTONS MILLS, MA Section No G.W. ENCOUNTERED Prepared for: Carol Hedlund, 19A Granite Street, Rockport, MA 01966 1500 GALLON CAPACITY, H-10 LOADING PERORATE < 2 MIN/IN. ("C" HORIZON) Engineering by: Surveying by: SCALE DRAWN JOB. N0. 500 GALLON CAPACITY, H-10 LOADING SEPTIC TANK EnginimiIingWorks HOOD SURVEY GROUP N.T.S. P.T.M. 84-04 CHAMBERS For stdole,West rMAf1eld 02644d Sandwich, MA 02563 DATE CHECKED SHEET NO, N.t9. N.T.9. 1 (508) 477-5313 (508) 888-1090 9/16/04 P.T.M. 2 Of 2 r i A / tp LEGEND rt / / Shubael `- 99 PROPOSED CONTOUR Pond Lakeside �r Calvin Hombli \ 99 PROPOSED SPOT GRADE Flint St Road EXISTING CONTOUR 110 EXISTING SPOT GRADE U 57r-06� 5 E TEST PIT Vol, a QT 68'� - BENCHMARK / W------ EXISTING WATER SERVICE ; APN 101 -059-00 I s LOCUS / (LOT 58)23,265± 5F old Falmouth Rd / �� ��, BENCHMARK: 9TAKE/fACK 5ET / :4 D ~ ELEV. - 100.00(A55UMED) M � / oss F� ` h C�F 1101 o / `Ot1 oLOCUS MAP N.T.S. GENERAL NOTES: EX157INGCE55POOL / M �: o 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL TO BE PUMPED,RULED L o p t 29, GARAGE BOARD OF HEALTH AND THE DESIGN ENGINEER. W/SAND,AABANDONED 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE / 5EWERN� 2 LOCAL RULES AND REGULATIONS. / (SEE NOTE 12) O 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 1 Nw:� �v I �i N TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE �`` DESIGN ENGINEER, 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 5EWERNO. I �' oec I to FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN / V. EL=99.25 f �? / 10 PROM HOUSEII in ENGINEER BEFORE CONSTRUCTION CONTINUES. i REPLACE W1 5CH 40 PVC/ No.379 I in 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.C� z4 BDRM. ! x 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF G 2 9TY.WD.rR THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF T.o.r. 163.1 I HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. f 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. coves ' 1 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. PORCH AREAS `1 I 9 TOLA CONDITION UAGREEDUUPON CONSTRUCTION RESTORED OWNER AND CONTRACTOR. m,5`L'� 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. FL/NT ''---_ __� ""�---'" AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). 12,V ,p� . ALL EXISTING SEWER OUTLETS FROM THE DWELLING SHALL BE FOUND C.��" ./ OF Mass AND ALL SEWAGE DIRECTED TOWARDS THE UPGRADED SEPTIC SYSTEM. - 40' WIDE) PETER T. (PUBLIC �-- af MCENTEE SEPTIC SYSTEM REPAIR/UPGRADE CIVIL No. 35109 N MARSTONS MILLS, MA 379 FLINT STREET, RFGISE��`� ��� Prepared for: Carol Hedlund, 19A Granite Street, Rockport, MA 01966 FFSS/ONAL E� Engineering by: Surveying by:. SCALE DRAWN JOB. NO. I, EngineeringWorla HOOD SURVEY GROUP 1 "=30' P.T.M. 84-04 4 �[ � 12 West Crossfield Road 18 Route 6A } t Forestdole, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO. (508) 477-5313 (5os) ssa-logo 9/16/04 P.T.M. 1 of 2