HomeMy WebLinkAbout0038 JASPER ROAD - Health (�I Jasper Rd.(Marstons Mills)
T04.7-Q16
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� I
,M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address ISJ
Robert A. Rogean and Jagueline S. Cronin
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 December 27 2016
page. City/Town State Zip Code Date of Inspection
CA
RJ1
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. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
Company Name
155 George Ryder Road South
Company Address
Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes pat"oFMgssgc ❑ ,Conditionally Passes ❑ Fails
DAVID yes
Needs er E�luatio he Local A
❑ Approving
COUGHANOWIR N g Authority
N .13 8
December 27, 2016
Inspectors Signatu 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
'***This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. 1�
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27 2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A).System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* orthe septtc-tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failurets imminent. System will pass
inspection if the existing tank is replaced with a!6omplying 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 2&years old+is:available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27 2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
�a
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27 2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑
Backup of sewage into facility or system component due to overloaded or® clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M ,• 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27 2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ - the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you'have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27, 2016
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ 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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 127 gpd
9 ( Y 9 (gpd)):
Detail:
2015: 42,000 gallons 2016: 51,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?. ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�^M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
p Y
Robert A. Ro9 can and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'' 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jagueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 38+ years Certificate of Compliance for a new system was issued 5/23/1978 (Permit#78-34 at
Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank (locate on site plan):
Depth below grade: 0.5
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: 8.5' x 5' x 6-1000 gallon
Sludge depth: 6 inches
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is Marstons Mills MA 02648 December 27 2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
of sludge to bottom of outlet tee or baffle
28 inches
Distance from top 9 ,
Scum thickness
1 inches
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined?
As built card
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not requireded at this time. Maintenance pumping is recommended every 2-4 years with
year round occupation. Tank and tees appear structurally sound and functioning as intended. No
evidence of leakage in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27, 2016
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No adverse conditions observed.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the
stone or overlying soils. Standing effluent was observed at a depth of 2 feet below the top of the
peastone layer.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):.
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
LEACH i� EC®'T
PIT
DISTRIBUTION BOX
NOT 1000 GALLON O
TO SEPTIC TANK
O •G
SCALE
A B 508 364-0894
DME UNG L O CA T§O YS
03(8
—OF SEPTIC COMPONENTS
—DISTANCES IN DECIMAL FEET
A B
1 24 16
LU
2 44.5 42
Cr 3 67 75.5
L
Q
3
JASPER R IDQ D THIS SKETCH IS
BEST VIEWED IN
COLOR FORMAT
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jaqueline S. Cronin
Owner Owner's Name
information is 27 b
arsons MillsMA 02648 December ,
required for every M 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 35+
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: 5/23/1978
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:
Town of Barnstable GIS maps
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows a witnessed test pit in which no
groundwater was encountered to a depth of 12 feet.Town of Barnstable GIS maps indicate that the
property is over 35 feet above the groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 38 Jasper Road Assessor's Map: 47 Parcel: 36
Property Address
Robert A. Rogean and Jagueline S. Cronin
Owner Owner's Name
information is required for every Marstons Mills MA 02648 December 27 2016
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
GEOHYDROLOGICAL PROFILE
— NOT TO SCALE
I T 11 11 T 11 /P T ' I ll 11l
PRECAST I
LEACH PIT
+
(Y) BOTTOM
OF
LEACHING
PIT
LEACHING IS
ABOVE HIGH
GROUNDWATER
GROUNDWATER ELEVATION
PER GIS MAPS
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
,t >
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a 2
DEPARTMENT OF ENVIRONMENTAL PROTECTION
d
r
d
C
h
A
C
OW
/A 5y0 v
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 38 JASPER ROAD MARSTONS MILLS,MA 02648 0 4--) 0 - ,,
Owner's Name: LANNA NICKERSON
Owner's Address: BOX 696 FORESTDALE MA 02644
Date of Inspection: 6/4/01 RECEIVED
Name of Inspector: (please print) JOHN GRACI JUN ?. 5 2001
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 TOVvN OF BARNS 1 ABLE
HEALTH DEPT.
Telephone Number: 508-564-6813 FAX 508-564-7270
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 the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.3401of Title 5(310 CMR 15.000). The system:
:
X Passes
_ Conditionally Passes
_ Needs Furth r valuation by the Local Approving Authority
Fails
Inspector's Signature: Date: 6/4/01
The system inspector shall submit 1copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFULL LIFE.
****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.
,c
Title+ S lncnrrtinn Form 6/I S/?fl(1O 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACKSEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 38 JASPER ROAD MARSTONS MILLS,MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out`or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
cl
Property Address: 38 JASPER ROAD MARSTONS MILLS,MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply-
- The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply 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 n/a
"This system passes if the well.water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
i
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 JASPER ROAD MARSTONS MILLS, MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X Required pumpingmore than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nla.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X 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 coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this forma
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
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)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed, The owner or operator of any large system considered a glgnifieatit threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
n
Page 5 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 38 JASPER ROAD MARSTONS MILLS,MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks`?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
�( 5 Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ 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 `?
X _ 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:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CM 15.302(3)(b)]
5
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 38 JASPER ROAD MARSTONS MILLS,MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
r
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 —Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 1
Does residence have a garbage grincer(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required)
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1978 0
Were sewage odors detected when arriving at the site(yes or no): NO
r
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 JASPER ROAD MARSTONS MILLS,MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
BUILDING SEWER(locate on site plan)
Depth below grade: 14"
Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
n/a
SEPTIC TANK: X(locate on site plan)
Depth below grade: 8"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age°confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W4' 10""
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle:31"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
,Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 JASPER ROAD MARSTONS MILLS, MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction: ' concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
DISTRIBUTION BOX IS STRUCTURALLY SOUND,SYSTEM APPEARS TO BE FUNCTIONING PROPERLY.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 JASPER ROAD MARSTONS MILLS, MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number:
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow ce
sspool, number:
n/a
n/a { innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. THE LEACH
PIT HAS NOT HAD MORE THAN 3' OF WATER IN IT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
n
Page 10 of l 1
OFFICIAL INSPECTION FORM-NOT FO
R VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 JASPER ROAD MARSTONS MILLS, MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
eA 8
o A
Ac ti
PA dY
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i
in
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 JASPER ROAD MARSTONS MILLS,MA 02648
Owner: LANNA NICKERSON
Date of Inspection: 6/4/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
� � I
�o7- 7 36C
LO AT ION SEWAGE PER� NO. '
VILLAGE
IN.STA LLER'S NAME & A,DDRESS
BUILDER OR OWNER
pnl S 2
DATE PERMIT ISSUED l � � o
D A T E COMPLIANCE ISSUED S�o�3�7V
1
I( �
/-
G r w � �
No............... FEE..........:...... ._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...............TdWN...............O F.........B.ARNS-T.F>,BLE.--.---------•---............---....------------
Appliraation for Kiapnsal Works Tontitrurfivit Prrutit
Application is hereby made for aPermit,..to Construct (x ) or Repair ( ) an Individual Sewage Disposal
System at: r
Jasper Road i Lot 461
..................»_..__._._-__....___•__ ......_.•...-_•-•.........•.�..��`....................... ................................_....._......6. ................................................
Lo tion- dre ' or Lot No.
.. .. .... _1��. 2. `. .!.....�---._!XXp .................. 1 1.1�. � ,.�..5..... ...........................
Owner Address
!` Installer Address
Type of Building Size Lot.....ZQ.&800......Sq. feet
Dwelling—No. of Bedrooms..•............................_....---.--.Expansion Attic ( ) Garbage Grinder { )
Other—T e of Building No. of persons................. .......... Showers — Cafeteria
Q' Other fixtures ----------------------------------------------
W Design Flow....................55..................gallons per person per day. Total daily flow...............................330....gallons.
WSeptic Tank—Liquid capacity.l-00 Ogallons Length.-$.'.-.F_'.' Width.4.'--1.Q"Diameter................ Depth..5.1.-4....
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........ Diameter......... 0...... Depth below inlet..U.-.Q.'.'..... Total leaching area.....2.fi7....sq. ft.
Z Other Distribution box (X ) Dosing tank ( )
Percolation Test Results Performed by.Cape_-CO ..- 1,i7:�7�y...CO11S.U3' aT.ltZ)ate...Jan.... A.....1-9.7.8
aTest Pit No. 1--- /.�.....minutes per inch . Depth of Test Pit......12........ Depth to ground water.......none--_
Test Pit No. 2................minutes per inch Depth of Test Pit...--............... Depth to ground water........................
P4 ............••--•-----•--•-••--•..................•-•••----.....................................--••.........................................................
0 Description of Soil........q-.0 5_wood loam,-..0-.5--2_,.5__.sub$4,-1,�_--2-,-5-$- Q.-. e �, -
v .............& gravelz 8 0 12 0 white sand l �� t gxave�....•.-.. yy4P.j MAss90
---•------------------------------------ --------- -••-• . •---•--- -----••• •--•-.... .. .-••-•-• -•--••. ••..-- •--•.••• -----•--•-•••••-• }�fitYddfE1K tiN
U Nature of Repairs or Alterations—Answer when applicable.................................................................. Z.- B.........
o0 CA
MAN ti
-----------------------------------•-•-•----•--------------------•------•-------•--......................----....-------•------.................--••-••-••••--•••••••-••• --- --•-•-•--•-......•...
Agreement:
A�No. 27654 p
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in
the provisions of'1 ITLY 5 of the State Sanitary Code—The undersigned further agrees not top
operation until a Certificate of Compliance has been issued by the board of health.
ned.. .. .....' ...............................................................
Date
Application Approved By............... ...•... ...... Gr!J!1. . ................ ---/.... Date
Application Disapproved for the following reasons:..............................................................................................................
.............................•----....................-•-----•------------...................----•-----...-----------------------------------------------------------------------------------------.-•---
Date
PermitNo......................................................... Issued......6 ---------
Date
No........... - •--- FEic..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............TOW....--..---••--.OF.........BAMS.'I'ALE._.............---•-----.......................
Appliration for Disposal Works Tontrnrtion Frrutit
Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal
System at:
.. Jasper Road ..............................Lot 461
�� Lo tion-Addre / ,(fir or Lot No.
-rt ,� , ..r...�..r?...._ 7 ................... ...�... r 1...I......................................-_.....
Owner dress
........................ ...- ........................................ ............................ .................................................
Installer Address
dType of Building Size Lot.....20-,_800------Sq. feet
U
Dwelling—No. of Bedrooms.....................3.....................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons.................t--------. Showers ( ) — Cafeteria ( )
a Other fixtures -----•--•-----•-----•---•--••-......-••--•......•. .
W Design Flow.....................55.................gallons per person per day. Total daily flow................................330_...gallons.
WSeptic Tank—Liquid capacity-1QO.Qgallons Length...8.'.-E.j1 Width:4.'--10-7 Diameter---------------- Depth-_-
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........ Diameter.........1Q-.... Depth below inlet-_6-.'=10. ..... Total leaching area......Z5.7....sq. ft.
Percolation Test Results ` ) Perform Dosing tank ( )
Z Other Distribution box
•
ed.bY•Cal?e--=CQSx...survi�y..�S?njau1t3n'Zw Pate.... ALn-.----1$-s---.1.9.7.8
Test Pit No. 1...ll2.....minutes per inch Depth of Test Pit......12,'...._. Depth to ground water-.---.---QnS'......
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ......._.. -------•-••--_...
O Description of Soil........0-0._S_._c ood...low,,.,0.,5-2,.5-__subso ].,{,__-2117- 0_•medi___._ °F
x & gravel1
UW 8.4 12.0whitesand & light• _ , „ _-- .-- -_ „-g �z RERMCK
--••••-----•-----•.......................••-••••••-•--...-----••-•-••-•-••-•-------------•---•---•----••-••----•------------------•--•--•-----•-----•-----•----•.....-•--.. goyG o...........$......
UNature of Repairs or Alterations—Answer when applicable.................................................................... �! ....J.HAP.N.AN y
--------•---•-----••---•...............•------------•---•--------•--•-•---•----•--•-•-....-----•--------••--•---------------•-•----•------------••••-•••-••-.......-•--••••--• .4- fi� No,-27E,54.0
Agreement: � sTE���`�``
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac s @blAtri 6
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to pla e sy
operation until a Certificate of Compliance has been issued by the board of health.
S' ed... ..... ............................................................... ................................
�at
Application Approved B '"' :... ..... .. ..... . .................. ""
Date
Application Disapproved for the following reasons----------------•------------ -----•-----------------•------•--•-----------------............................._..
..........••--••---------••••.......................................:...............................•••--•-•--------•---••••--•-----•---••-----•---••--•-----••--•---•---•••---•.............------_._..
Date
PermitNo.................................--........------........ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,BOARD OF HEALTH
Trrtifiratp of TonmpliFana ,,,.
THIS IS TO CERTIFY, That the Indi •dual' Sage Disposal System constructed ( ) or Repaired ew ( )
by........................�.......•--.....--•-•-...........--`-------------- .+. -•---•--•--........-•----•--.........------•--•-•---------•-•----•-......------------
at fi"f• Installer
" f....... ......f f f=a---. ..1. •.........................•--•---•--
has been installed in accordance with the provisions of T&�.V r of The State Sanitary Code as described in the
application for Disposal Works Construction P,ermit No ..-�-1-Y................. dated....f-- -- -."':7 '.'........_..._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................•-•-----•------•----••-•-•----.........._......---••-•-•••-•---- Inspector:...................................................-...............................
Z'-THE COMMONWEALTH OF MASSACHUSETTS
BOARD Z HEALTH
.............. "tr....OF............ .. .. .............................
No... ... ` FEE..... ..........
Disposal Works Tontrnrtion rru it
Permission is hereby granted.......... ``-- ' ---'----------------------•--------.............--••--•----•---•--------•........................--
to Construct r Repair ) an lndiviq uaa Seer e D,,i po System
atNo.--• --- y��--- �"R - �� � ►'----------------••-----...----.............------......-----••••............._....
Street
as shown on the application for Disposal Works Construction Per No.. --_.. Dated "2 -.. . '. •......:
•....................•...---....•••..........-- ....-- Board of Heal
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No.-A --- - � Fee----- �^-- -
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplicationArlVell Con$tructionAermit
Application is hereby made for a permit to Con truct ( ), Al. q, or Repair ( )an individual Well at:
------------------ ----
Location — Address Asselsors Map and Parcel
� Owner Address
--DA---J_�lt,.�, c G --- ——— —---- — ---- --�/ --------
` �c_�Nvf�-�— `,-- '1'°a F �'------- ---------- ------
Installer — Driller Address _
Type of Building
Dwellingf - ------------------------------------------
Other - Type of Building-------------------------------- No. of Persons-------------------------____—_—________
T ��--- --- - - --
YPeofWell— - ------------ Capacity-------------------------------------------- ---------
Purpose of Well-&Li:K cS 7`•c-----------------------— ——-
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate . Co iance has been issued by the Board of Health.
�C�wG� L.eu�..
Signed ------------------------------------------- ---
date
Application Approved By- — -- — —- -— —�- -o ---------
----_ date
Application Disapproved for the following reasons:-------------------------------------------------------------------
---------------------------------------
--------------------------------- ------------------------------------
- -------------
date
Permit No. ---- `' -=- ��--------—-------- Issued-------
--------------------------------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of Compliance
THIS IS TOffJFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ''}
bY----------------- - -- == - -———-—--------------------------------------------------------------------- - -----------------------
Installer
at 3$- tJ�e `'
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. kV-a!4�?---Dated ------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------——---- — — —--- Inspector-------------------------------------------- -----------
r -r:.�„�.,^GT�;'o�-t�'sf�''�N:."z.'�Ft�'.d`'��s�''"ic'+r.��'"i''�x`"s'_n�._r„�t`LL�yl�f�L�i�^�."�yx+d'l'"d �.Y..fRM�!� +�.'"►�►�y �""7'�{'p"�"*""�''ti.Ff-F�Zla����nJY,fy�.r.'C"� �
No. ---- Fee---- --
BOARD OF HEALTH
TOWN OF BARNSTABLE
���Cuation,�or�eCC �on�truction�ermit ��
Application is hereby made for a permit to Construct ( ), Alter (a), or Repair ( )an individual Well at:
-------- -----------------------
T—"—-T
Location — Address As Map`and Parcel
�
—` ..c�-- r e K "'Cr,--J — --- --- --- — - 'L4��a�------ -- `c f3 ru.✓S iu r
/ Owner Address /
----------------------------------------------- ---- ---3� o�,,c�� + ,,.�.,°J L 'L'4
------- ----
Installer — Driller Address
Type of Building
Dwelling _/r �_t f- ------------------------------------------
Other - Type of Building--------------------------------- No. of Persons------------------------------ ---------
Type of Well- - - -- - ------------------------ -- - Capacity---- - -- - --- - - --- —
Purpose of Well-�o..r� �`CS - --- --- Ir
I
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until
a Certificate .o Co/mp�'ance has been issued by the Board of Health.
Signed --------- J-All-/--�tL--------
date date
Application Approved By —'-� J u - - =------- -— _ � ��
— date --
Application Disapproved for the following reasons:-
--------------- date
e. , i
Permit No. -- [j /'' Issued------------------------------------------- — ------------=
�sG-P--��—=---v—�--���--------------------- date
I
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERT FY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( °
by- -- P.Q= r/ - ------------------------------------ -- -- --- ------
Installer
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. - y= - ---Dated-------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE`WELL
f
SYSTEM WILL FUNCTION SATISFACTORY.
iDATE-------------------- ---- ----------------- - - - Inspector--------------------------------------- --—-
I
BOARD OF HEALTH
TOWN OF BARNSTABLE
VrIt Con5truct ion Permit
No. W-IV n a.-k Fee— -�� -----
.0 A fc4,...�.,. �/ -
Permission is hereby granted--_ --------------------------------------------------------- -:-----------------
to Construct( ), Alter ( ), or Repair (x' an Individual Well at:
No. ----------------3 --------- S P - -- -------------------------------------------------------- ----------------- ----------------------------- -
street
as shown on the application for a Well Construction Permit
o.- - -�- -N ? }
------------------------------------.-.. ..... -
Board of Health
DATE---- �. f `
i
I
i
I-
TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
f -,
ADDRESS:l9 j': '=rR MAP NO. I7 t� PARCEL NO. '` �a
OWNER NAME: k._� o f� �y 1 C.h '�S�aJ VILLAGE: Via C�s'Fz-�Y1 G H)
INSTALLATION DATE: I BY:
ADDRESS: CERT. NO.
7 (0 TANK INFORMATION
LOCATION OFF/TANK: ) / /
CAPACITY ::J�✓� TYPE V! � AGE FUEL/CHEMICALC�. 1 (l .L �1��
TESTING CERTIFICATION C I PASS C I FAIL DATE
LEAK DETECTION C CHECK IF N/A TYPE/BRAND Y
ZONE OF CONTRIBUTION C x] YES C ] NO DATE PTO BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES C I NO DATE
UUNSERVAiION C )K CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. V ]C ]C 71 ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD ",
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GAL. PRECAST OR ° ° a
SEPTIC 6 �00� BLOCK °o °°pI -
TANK 1�'° ° e SEEPAGE PIT SQL
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20' MINIMUM oo°• �0 7 'p �.0 � '� 9 6�C�$?i5ly! �
FOUNDATION I e,
I %: WASHED STONE a '
1 �y C�rzn =y r�,*7 '�.'�� ?�Ssteee'fu�� t � rJ,4;e
I 5� •iq&aA ao-4*, w i�5 Lyc.r4Tx t�� / 190a IO PERC. RATE
pcT--c Fe&,4 Su•ze�E�. aN DAC� 2u, /y77 vvz5/&.A/ 3Zf7 TEST BY :
►�N> tow.�o�,r�s yc �c` Zo.0 1;�� s7ifr-Lows NO C�'e8"f6e o2/A1z2,.5'X TOWN INSPECTOR
GAF 746 70.3,4 e F t�o>�:eeeST��SIF, 41q55 7r2;" zie �,L•� BACKHOE OPERATOR
TEST MADE ON
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ELEVATION SCHEDULE 1 ,� rE^;�'rICK c
PROPOSED SITE PLAN '
Ilk `� CLIAP ,a�a
I INV AT FOUNDATION _ I j,aJr `��N +. 27 'I<- a J
SEWAGE SYSTEM DESIGN 0/�l S�
2. I NV. INTO SEPTIC TANK IN 0"AL '
3. ' NV. OUT OF SEPTIC TANK f1JAA >5rflr*s /ru4l�cy
4 INS. !NTO DISTRIBUTION BOX SCALE I° ►� C 1977
i
5 NV. OUT OF DISTRIBUTION BOX -
6 INV INTO SEEPAGE PIT - �z8,70 CAPE COD SURVEY CONSULTANTS
ROUTE 132
v 7 BOTTOM OF PIT C! HYANNIS, MASS. ' _
- A DIVISION BOSTON SURVEY CONSULTANTS, INC-
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