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HomeMy WebLinkAbout0052 JASPER ROAD - Health 52 Jasper Road Marstons Mills P A= 047 037 I c Commonwealth of Massachusetts 0L f C 3} - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Jasper Road Property Address P Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 51 153�� on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road ITV Company Address Teaticket Ma. 02536 City/rown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system,inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address 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 04-03-2021 In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate 4 regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 1. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road v� Property Address Paul t-anoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding two 500 gallon leaching chambers with stone. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts ,10 Title 5 Official Inspection Form m � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '0 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is Marstons Mills MA 02648 04-01-2021 required for every I page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments >r 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, pertormed 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 ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts ,M1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributaryto a surface water supply. ❑ ® 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 fails. 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 th g y g y e system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth, of Ma ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 3 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Town water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Jasper Road Property Address Paul l-anoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5ins .doc•rev.7/26/2018 / P Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 8"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was in place. The tank is scheduled to be pumped after the inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title n - � 5 Official Inspection Form Subsurfacew Sewage Disposal System Form Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown 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: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form w, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road V Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. i i 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road L Property Address PaulLanoue Owner Owner's Name � information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts (P Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is Mills Marstons MA 02648 04-01-2021 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) j i 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 A $AlLik B D� I ' I I � t 0 A 13 a r 3� ry a ya a4 0 3 3 Lfl 3y t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form I- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Jasper Road Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) I ❑ 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: I augered a hole at a Power elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Jasper Road u Property Address Paul Lanoue Owner Owner's Name information is required for every Marstons Mills MA 02648 04-01-2021 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 cf Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP PARCEL TITLE 5 LOT OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 52 Jasper Road Marston Mills, MA 02648 Owner's Name: Craig Decker Owner's Address: _ Date of Inspection: May 23, 2004 L Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford co i Mailing Address: P.O. Box 49 CD -� Osterville.MA 02655-0049 �- Telephone Number: (508)862-9400 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that 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 Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 7�Inspector's Signature: Date: May 31, 2004 The system inspector shall subm copy 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 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 52 Jasper Road Marstons Mills. MA Owner: Craig Decker Date of Inspection: May 23, 2004 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: 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. 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: 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: 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: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 52 Jasper Road Marstons Mills. MA Owner: Craig Decker Date of Inspection: May 23, 2004 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(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 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 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: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 52 Jasper Road Marstons Mills MA Owner: Craig Decker Date of Inspection: May 23, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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.) No (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 System: 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 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- I WPA)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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 52 Jasper Road Marstons Mills. MA Owner: Crain Decker Date of Inspection: May 23, 2004 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 sew age 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: Yes No ✓ _ 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(3)(b)). 5 Page 6 of 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 52 Jasper Road Marstons Mills. MA Owner: Craig Decker Date of Inspection: May 23, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: / Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 6119197-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 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: 52 Jasper Road Marstons Mills, MA Owner: Cram Decker Date of Inspection: May 23, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: loft Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" 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: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leaky e GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 52 Jasper Road Marstons Mills, MA Owner: Craig Decker Date of Inspection: May 23, 2004 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property hAddress: 52 Jasper Road Marstons Mills, MA Owner: Craig Decker Date of Inspection: May 23, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 pal. chambers (25'x 139 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.): The chambers had 2"ofwater on the bottom. The scum line was approximately at the same level. There did not appear to be any signs offailure. A video camera was used for the inspection. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): I 9 f , Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 52 Jasper Road Marstons Mills. MA Owner: Craig Decker Date of Inspection: May 23, 2004 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. 8 AUK 8 �« 1 O A a a a ya a� o 3 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 52 Jasper Road Marstons Mills, MA Owner: Craig Decker Date of Inspection: May 23, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using a Barnstable topographic map and water contours map, the maps were showing approximately 40'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 ali ax COMMONWEALTH OF MASSACHUSETTS a a kiT'E'F , EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION ` rt; a y: i v� 4 z +b! TITLE 5 ^ t E� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS { SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ` PART A CERTIFICATION �* Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 Owner's Name: CLIFF HARRIS p +ap.1fly Owner's Address: 52 JASPER RD MARSTONS MILLS,MA 02648 Date of Inspection: 1/4/02 l�� Name of Inspector: (please print) JOHN GRACI �� i Company Name: SEPTIC INSPECTIONS ' Mailing Address: P.O:BOX 2119 TEATICKET,MA.02536 N 1 0 r Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE jaw HEALTH DEPT. i 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 tTq 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: {_ X Passes' '' Conditionally asses Needs Fu Evaluation by the Local Approving Authority _ FailsiI + Inspector's Signature: Date: 1/4/02 rx, K. The system inspector shall subm' 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 is a shared system or has.a design flow of 10,000 gpd or greater,the : Y inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The or should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. °„ Notes and Comments °` rx SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS. **** report only describes conditions at the time of inspection and under the conditions of use at that time.This,,r n . This r p y inspection does not address how the system will perform in the future under the same or different conditions of us®.' Titip 5 TncnFrtinn Fnrm rii�!,)non Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR-VOLUNTARY ASSESSMENTS a �k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' ` PART A s.. CERTIFICATION (continued) is Ipr Property Address: 52 JASPER RD MARSTONS MILLS,MA 026.48E ,m Owner: CLIFF HARRIS a Date of Inspection: 1/4/02 � . Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ` al i r' }„ 3 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. d Comments: SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS. t ` B. System Conditional) Passes: . y y _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, 11. upon completion of the replacement or repair,as approved by the Board of Health,will pass. sue. 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 exfiltrat�on or tank failure is imminent. System<will pass inspection if the existing tank is replaced i.. 141 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: 4� �, that the tank is less than 20 years old is available. ND explain: n/a 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): . � � ` 3 4�-Z _ broken pipe(s)are replaced _ obstruction is removed ` _ distribution box is leveled or replaced 4 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 i. _obstruction is removed `N ND explain: n/a � w. a- Ai ` Page 3 of 11 " { " OFFICIAL INSPECTION FORM -NOT FOR VOLUN"I i't V y° ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A : CERTIFICATION.(continued) i Property Address: 52 JASPER RD MARSTONS MILLS,MA 0.2648 r L .. Owner: CLIFF HARRIS k= i { Date of Inspection: 1/4/02 C. Further Evaluation is Required by the Board of Health: x _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to 4n , . _ :. protect public health,safety or the environments _ 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the system 4, Y � not functioning in a manner which will protect public health,safety and the environment: r _ Cesspool or privy is within 50 feet of a surface water i _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ;f 1 y�34 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the � ,az t system is functioning in a manner that protects the public health,safety and environment: x _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water, }art 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. i _ The system has a septic tank and'SAS and the SAS is within 50 feet of a private water supply well. has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water The systemp supply well**.Method used to determine distance n/a Cr3 performed at a DEP certified laboratory,for coliform bacteria and, **This system passes if the'well water analysis,p . 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. Y� 3. Other: n/a l �t Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �FS4 PART ' CERTIFICATION(continued) Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 tr Owner: CLIFF HARRIS Date of Inspection: 1/4/02 r D. System Failure Criteria applicable to all systems: �� You must indicate"yes"or"no"to each of the following for alLinspections: E } Yes No t= X Backup of sewage into facility or system component due to,overloaded or clogged SAS or cesspool F . X Discharge or ponding of effluent to the surface of the ground or'surface waters due to an overloaded or clogged k SAS or cesspool s _ 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 %2 day flow * . _ X Required pumping more than 4 times in the last year NOT to'clogged or obstructed pipe(s).Number of tunes R` pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. r' _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply iT. X Any portion of a cesspool or privy is within a Zone 1 of a public well. A 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 well water analysis, performed at a DEP P q tY Y [ Y P Y certified laboratory,•for coliform bacteria and volatile organic compounds indicates that the well is free`;r k s 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 $ ` i � attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in310 i ' Yes . . ,�. ! CMR 15.303,therefore the system'fails.The system owner should contact the Board of Health to determine what will be `k . necessary to correct the failurex'. M E. Large Systems: A . F 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 )w : _ 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 r" If you have answered','yes"to any.question in Section E the,,,system is considered a significant threat,or answered . i "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 1�shall upgrade the system in accordance with 310 CMR 15.304.The system owner wt i -` 1 should contact the appropriate'regional office of the Department. I tl �Y r 1 r f - Page 5 of 11 ak is� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST *'L �,ec Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 M � Owner: CLIFF HARRIS Date of Inspection: 1/4/02 Check if the following have been done. You must indicate"yes" or"no"as to each of the following: s, Yes No ti , X _ Pumping information was provided by the owner,occupant,or Board of Healthy X Were any of the system components pumped out in the previous two weeks?' T X _ Has the system received normal flows in the previous two week period? a X 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) X _ Was the facility or dwelling inspected for signs of sewage back up? Y X _ Was the site inspected for signs of break out - , w X _ Were all system components,excluding the SAS, located on site? r ��a X _ Were the septic tank manholes tittcovered;opened,and the interior of the tank inspected for the condition of the i,, ° 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 ;, r�i zn;. of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: r 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 CMR 15.302(3)(b)] ` �{a 5�p� G is {gk' at P i Page 6 of I I 0 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS WAGE DISPOSAL SYSTEM INSPECTION FORM SUBSURFACE SE .� PART C , SYSTEM INFORMATION x Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648e Owner: CLIFF HARRIS Date of Inspection: 1/4/02 FLOW CONDITIONS RESIDENTIAL <•, .�'a Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 &1 ' Number of current residents: 4 ! ;` Does residence have a garbage grinder(yes or no): NO +p Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] 4 Laundry system inspected(yes or no):,NO Seasonal use: (yes or no): NOS°gig `f Water meter readings, if available(last 2 years usage(gpd)): n/a +' Sum um es or no : NO P pump(Y ) Last date of occupancy: n/a COMMERCIAL/INDUSTRIALS I nfTt: Type of establishment: n/a Design flow(based on 310 CMR I5.203):,n/agpd " Basis of design flow(seats/persons/sqft,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 ' rr Pumping Records `"��" Source of information: n/a Was system pumped as part of the inspection(yes or no): NO Y = }{ If yes,volume pumped: n/agallons'--How was quantity pumped determined?n/a } 4 Reason for pumping: n/a TYPE OF SYSTEM' ` X Septic tank,distribution box,soil absorption system t. } Single cesspool _Overflow cesspool _Privy . '*e _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, ? }F system owner) _Tight tank Attach a copy of the DEP approval # Other(describe): n/a Approximate age of all coo`S onents,date installed(if known)and source of information: 1979 f V�,vJ k e1 qs Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 _ Hg OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS a 1- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) s` h� Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 Owner: CLIFF HARRIS Date of Inspection: 1/4/02 � + BUILDING SEWER(locate on site plan) f Depth below grade: 12" A' Materials of construction:_cast iron X40'PVC_other(explain): n/a Distance from private water supply well or suction line: n/a ' p PPY Comments(on condition of joints,venting,.evidence of leakage,etc.): TOWN WATER x SEPTIC TANK: X(locate on site plan) ' ,f t Depth below grade: 6" of eth lene other(explain)n/a < rete metal fiberglass Material of construction: _ _ _p Y Y If tank is metal list age: n/a 'I;s'age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)} Y. . Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10". Sludge depth:2" ' t* " Distance from top of sludge to bottom of outlet tee or baffle:32" � ��{ Scum thickness: 1" Distance from top of scum to top of outlettee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle,condition,structural integrity, liquid levels as related r to outlet invert,evidence of leakage,etc.): ; SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.' RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ,4 " GREASE TRAP:_(locate on site plan),,, p 9 Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a ; Dimensions: n/a " Scum thickness: n/a M+ 1 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 $' 3 Date of last pumping: n/a ," Comments on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related v k s�ry to outlet invert,evidence of leakage,etc.): �tFr n/a t. A h 4: 7 Page 8 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C 3 � : � . :<. SYSTEM INFORMATION(continued) Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 Owner: CLIFF HARRIS y Date of Inspection: 1/4/02 `h TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) w w# Depth below grade: n/a l?' a IN-, 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 {w-0"w x Alarm level:N/A Alarm in working order(yes or no): NO n Y ; f Date of last pumping: n/ai' Comments(condition of alarm and float switches,etc.): 't n/a , DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) f 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 k. or out of box,etc.): ; D-BOX IS STRUCTURALLY SOUND:" s � PUMP CHAMBER:_(locate on site plan) ax; 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.): a { 1 n/a F � °t1T C : d7lLf st4 , r , CY Nei , xfX Page 9 of 11 t OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS F. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '�{ . SYSTEM INFORMATION(continued) Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 4 Owner: CLIFF HARRIS s �R Date of Inspection: 1/4/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a ^. . Type n/a leaching pits, number: nlay , 500 GALLON DRYWELL leaching chambers, number: .y. 2 s CHAMBERS leaching galleries, number: 0 ° :s K v.; n/a leaching trenches, numberjength: n/a � f: n/a leaching fields, number: n/a � 0 overflow cesspool, number 0 n/a innovative/alternative system f r n/a Type/name of technology: n/a �' Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.). CHAMBERS ARE STRUCTURALLY SOUND AND FUNCTIONING:PROPERLY.CHAMBERS ARE NEW AND HAVE NEVER HAD MORE THAN 2" OF LIQUID IN THEM.BOTTOM IS AT 5. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) .Number and configuration: n/a ¢" k: 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 Srz- Materials of construction: n/a `r Indication of groundwater inflow(yes or no): NO ,L j Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a a PRIVY: (locate on site plan) ,a� Materials of construction: n/a Dimensions: n/a 3, Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): ,, K n/a 5 ' k�' Page 10 of 1 'A OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �'�< PART C. SYSTEM INFORMATION(continued) t`t r t+� Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 Owner: CLIFF HARRIS ; Date of Inspection: 1/4/02 �t '? 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. } � a - y �A�§.µ' Ili beeL AA RQ V a T Ab 3y ,c q o C , ,r Ab 1 O �b 4 t ' �; of �f p.: n rQ Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C r SYSTEM INFORMATION(continued) "° Property Address: 52 JASPER RD MARSTONS MILLS,MA 02648 . Owner: CLIFF HARRIS '' w Date of Inspection: 1/4/02 ��� � P k k SITE EXAM ' Slope V _ Pe _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: r � 1 V NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a ''"' YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a � °L NO Checked with local excavators, installers-(attach documentation) gar' YES Accessed USGS database-explain: n/a z t You must describe how you established the high ground water elevation: DETERMINED BY HAND AUGER AND USGS MAPS AND CHARTS. 12+FT. i M1,pry j a� i t ifi � w- { �,�• �tea,. • ♦ 1 5 f_� y .. t; I P K _ ci COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 52 JASPER RD. MARSTONS MILLS MAP 047-PAR 037 LOT 460 Name of Owner SCOTT KELLERHERr, Aa 1 Address of Owner, 6561 CIR.10 S ALAMOSA CO.81101 � Date of Inspection: 9127/99 1pe, Name of Inspector:(Please Print)JOHN GRACI t , I am a DEP approved system inspector pursuant to Section 15.340 of Tltle 5(310 CMR 15.000) � rod 9 Company Name: n/a y�o, Mailing Address: Na Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evalua on By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: l�` - Date:9/27/99 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.. f the system is a shared system or has a design Flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/913 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Ilf PART A CERTIFICATION(continued) Property Address: 52 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. , Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 52 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27/99 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 the public health,safety and the environment. 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. - The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, - The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nta-(approximation not valid). 3) OTHER nLa revised 9/2198 Page 3 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 62 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an 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 1/2 day flow, X Required pumping more 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 52 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27/99 Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. ti revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 62 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):A Total DESIGN flow: = Number of current residents:4 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):..pLO Seasonal use(yes or no):DLO Water meter readings,if available(last two year's usage(gpd): n& Sump Pump(yes or no): NQ Last date of occupancy: n& COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):Na Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) nLa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NQ If yes,volume pumped W& gallons Reason for pumping: n& 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: NEW SYSTEM IN 1997 PERMIT 97-294 Sewage odors detected when arriving at the site:(yes or no): DLO revised 9/2/98 Page 6 of 11 SUBSU RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27199 BUILDING SEWER: (Locate on site plan) Depth below grade: 1C Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: 8_ Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nCa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:J 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: n(a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: n& Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:ji& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa revised 9/2/98 Page 7 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: Wa, gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:jV& Alarm in working order:Yes—No—: NQ Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTON BOX IS STRUCTURALLY SOUND PUMP CHAMBER: MO (locate on site plan) Pumps in working order:(Yes or No): IYQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 1 t l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number: Wa leaching chambers,number: 2-600 DRY WELL CHAMBERS leaching galleries,number: ji& leaching trenches,number,length: Wa leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: Wa Name of Technology: 1]/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE SAS IS FUNCTIONING PROPERLY. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: nLa Depth of solids layer: n& Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: nLa Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)Wit Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:nLa Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLE_RHER Date of Inspection:9/27/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 16- revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 JASPER RD.MARSTONS MILLS MAP 047-PAR 037 LOT 460 Owner: SCOTT KELLERHER Date of Inspection:9/27/99 NRCS Report name: Wa Soil Type: Wa Typical depth to groundwater: nLa USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE LOCATION 5a S ASPe r RG SEWAGE # 'r- 0 ' VII.LAGE M�_Mt��S ASSESSOR'S MAP & LOT O�I7- 037 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a• S� �„f. CAAK4 arx 13, `LEACHING FACILITY: (type) /1(size) ii NO.OF BEDROOMS 9 BUILDER OR OWNER CrAls beJ", PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi�g facility)T Feet Furnished by �,lIad e� � B BAUD O a . 3� ly 3 3 Lo 3y TOWN OF BARNSTABLE 'LOr,AV-I?N S SEWAGE # U—2 9 Y VILLAGE M4PSrOd5' !'yA ASSESSOR'S MAP &LOT o 1/7— o 7 INSTALLER'S NAME&PHONE NO. Jo 3 c f Dc LIA2105 SEPTIC TANK CAPACITY /d 0 // LEACHING FACILITY: (type) �; G01, (f4* 6'5 (size) IS-X 13 NO.OF BEDROOMS // RMILDER OR OWNER �f,*41 #,4 ald5e PERMTTDATE:6= 17,m.77 COMPLIANCE DATE: G _�9 97 Separation Distance Between the: ` Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by_����Q .z J�s�p�/' /2� ._� (j� � �� i OG�k � � �ti .6. ems_ 0� 6dlroR � �o No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es ZIPprication for 30i5pozar *pztem Construction permit Application for a Permit to Construct( epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S'"2— , xp,,-^ A Owner's Name,Address and Tel.No. Assessor's Map/Parcel o el 7_ 6'5 7 p � , r5 rotes - I/ If Installer's Name,Address,and Tel.No. el`7-7— d 3'elf Designer's Name,Add ss and Tel.No. .Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) m A/ 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 this oard of Health. Signed Date l 7— VIZ Application Approved by Date Application Disapproved for tV folio ins reasons Permit No._ 7- a- '-J Date Issued No: �+ g ,� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ves PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2pplication for Miopooar *potem Con.5truction Permit Application,for a Permit to Construct( epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components C Location Address or Lot No. .4 Owner's Name,Address and Tel.No. 4 r Assessor's Map/Parcel o y7_ 17 Installer's Name,Address,and Tel.No. 4�1 7'7— O 3 4 Designer's Name,Addr s and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Y.. Nature f Repairs or Alterations(Answer when applicable) i. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system 2 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 i ued by this oard of ealth. Signed ..L Date l— 9'— 9' ~- Application Approved by Date Application Disapproved for the follo ing reasons Permit No. Date Issued ` --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( 4,AfRepaired( )Upgraded( ) Abandoned( by a.S!W aHv d S at $�� �,�5'�F_l' R0,061 Tow S ill i Mc has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 97. ,29V dated .o— Installer�J�5:cd 4 0-4 16#rro s Designer �os•eio /3.2e s The issuance of this permit shall not be construed as a guarantee that the system wil unction as designed. Date / :m 'Ze9 q`) Inspector --------------------------------------- No. - L-/ Fee I/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLES MASSACHUSETTS Miopozaf *potent Construction Permit Permission is hereby gganted to Construct(\,4 Repair( )Upgrade( )Abandon( ) System located at 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:Constructions must be completed within three years of the date of this permit. Date: 1 q 7 Approved by NOTICE: This form is to be used for the repair of failed septic systems only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT OUTHOUT DESIGNED PLANS) I, _Jes-e104 Oe- s ; hereby certify that the application for disposal works construction permit signed by me dated e� q— 1?7 ; concerning the property located at Y2 J eN meets all of the following criteria: 6 There are no wetlands within 300 feet of the proposed septic system i There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED:- DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert J�sp.e-r A/ t O TOWN OF BA.RNSTABLE LOCATION SEWAGE # VILLAGE f;IarslohS /'fli�� ASSESSOR'S MAP& LOT D 5'7 o 77 'INSTALLER'S NAME&PHONE NO. Jo 3 r✓� Oc Q�r�OS SEPTIC TANK CAPACITY /d 0 / LEACHING FACII.TT�C: (type) 2 -SDO (��� �hfr,�i-r5 (size) NO:.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: — 9 ' f7 COMPLIANCE DATE: Y7 ` Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Ed'iof Wetland and Leaching Facility(If any wetlands exist Within 300 feet of leaching facility) Feet Furnished by��. • 6. pc6 6dGa� � 1D � o(' #• A16C) 4-7_-�-, 7 ?, „ 3 s lO6ATION SEWAGE PERMIT NO. VILLAGE R. Rf /- S IN.STA LLER'S NAME & ADDRESS B U Il D E R OR OWNER 110 6 1- !/ ,Z/`!/,P/zl'� DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED a� qy o �QAIC OF J�fowr2 1 �S� / 719 'r Y � 4 . k Y � • 1r0� No. •- =�...... FES..........................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N ...........................TOWN...OF............BARNS`,I,'AB .....---------............................... ApplirFa#ion for BiopooFal Works Tonstrurtion "trutit Application is hereby made for a Permit to Construct (X) or Repair. ( ) an Individual Sewage Disposal System at: ................_...+���$? ...$As3C3.._... t�.fi Q...... ............ �/ /;� t �: �r sj� /I t S E/ .... or t o. ......... .. ....._........_..........�.+..` 7------------------•-•------ f /� ................... Ter a -=...--� '" Installer Address Type of Building Size Lot....... Q.r.QQQ....Sq. feet U Dwelling—No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............6............. Showers — Cafeteria a1 Other fixtures .................................. Design Flow........15...............................gallons per person per day. Total daily flow...................3 0.........._..._..gallons. WSeptic Tank—Liquid capacityl.OD,.j.gallons Length.,'.-6.i'. Width..41:n.la'Diameter................ Depth....!!!.:n& x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------- Diameter..._1.4+:,:_.. Depth below inlet... Total leaching area....2-67.....sq. ft. Z Other Distribution box ( Dosiri tank '—' Percolation Test Results Performed byrape_Cdd...Sj_1.vey..Col.%u t,3r1tSDate:_._J rt.... ..... .3 . ,aa Test Pit No. L._. ..3_..minutes per inch Depth of Test Pit.....12.1._..... Depth to ground water.._1�L0IIe...... ' Test Pit No. 2................minutes per inch Depth of Test Pit.....................Depth to ground water......... t ------------------------------------------------------------ ----------------------.----.---------•---•----•--•-•----•---- 1,ZY..�F.d? D Description of Soil..........0---•n-�5---wood-.,loam•.••--�'•, - �. : 1 2• s -_!� 1rLerl ���......----- . s�90 v .zllow---sand--�-- 'aue�.,~ ._0.-�.Z�-�!--z�� i e saner__�...1 RENWICK ya R. - gravel----------------------------------------------------------------------------------------------------------------- -� - �•----EttRPta�RN v, U .: -----------------••---•---•--...---•--•-••----------- -----------------•-•--•--•----------•--•-•---•--•-----•----------------------- Ago Nature o Repairs or Alterations—Answer when applicable...............................-___--•---------------_-__---_------. s Agreement: S�ONAL EN6 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor the provisions of TITIZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue�y t ebo, d,of health. Si ned - ' �--------------------------. ----•-----•--•.---_.... •�� Da Dr . Application Approved By------- ---------....... ......................................... f/ Date Application Disapproved for the following reasons:................................................................................................................ ....--•-----------------------------•----....------•-----.....•--••-••-•••--•---------•••----•--••-•---•.--•--•------•--------------•-•-------------•----•-•---•--------••-----•-------------•-•-------- Date PermitNo.......................................................- Issued...........`............................................ Date THE COMMONWEALTH'OF MASSACHUSETTS BOARD QF HEALTH �4rJ'Yt GL.,iy ,Q% .......... ..............................O F...............:....... .................................... Trrtifiratr of Tompliatta v THIS IS TO CERTIFY, That the Indivi al SVtgeAj0nj6sal System constructed ( ) or Repaired ( ) by...................••- I . ��.�_..... .................... ............................................................. Instai..)-------------••---.. �.........._..--•-----------^------ at-----------•-- -••............................... ...... ..............•--...........-•-----•---•------ has been installed in accordance with the provisions of ` of The State Sanitary Code as described in the PIPapplication for Disposal Works Construction Permit No............�$"................... dated....../_"`9..4�..'7 .'_....._........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................•--•-..................-------••---•--_._._. Inspector.................................•.............r------------•-•-••-•---•--••......-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. ....... ` .... FEE........................ Disposal VorIA �11 # ion rrntit Permission is hereby granted................. :._..........__.......---••---.......... •------------------------ ...-.-------.,...,.....,........._.. to ConstrygE ( ) or W I ) an Ind' d 1 Sevt e D C s�e%stem tp�C �l/�ss at No..... ` Street t Z as shown on the application for Disposal Works Construction P it .._ Dated....___ ______________.............................. 001 ----------------------------------------- ' Board Health DATE..........................................................................: FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No............ .---- Fim... ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... ...TOWN....O F...........BARNS TABLE ....................................................... Appliration for Disposal Works Tonotrnrtion Vprrutit Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal System at Jasper.Road .I,ot 460.....................................................__. •••......_...........-•-••-•........._....... ...4 6. cation A dre s or Lot No. • .: .. ... - ... �`L. .� S Q- .. ?� ........................ /. 1�1.!-- ------------•--•--...........-••-............--- Owner Address a ........ - = -s�.,f .. ............................. .! !4r-.4.......................................... Installer Address 20, 800 Type of Building Size Lot............................Sq. feet_ Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aOther fixtures ------------------------- .............................................................. Design Flow............................................gallons per person per day. Total daily flow..................330 gallons. 04 W Septic Tank—Liquid capacitylO.0.0..gallons Length.V 6".. Width.-'.-1-Q."Diameter................ Depth.... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...........L....... Diameter....10.'......... Depth below inlet...6'.-Q.'_._. Total leaching area....2.6.7......sq. ft. Z Other Distribution box ( x) Dosing tank ( ) Percolation Test Results Performed byC.ap-e...C ad...Survell-...ConzuItantSDate....Jan.._1_8_.....19.7.8 Test Pit No. 1....0_..3....minutes per inch Depth of Test Pit-----1 ......... Depth to ground-water...... S).K.IP._..__. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit....................Depth to ground water........................ •-•----•------------------------•-••--•-••-•-------•-------..........----------------..........•••--•......................................................... 0 Description of Soil.......... __..ub.s-oi l......2..•.Q.-A,9...ma a�u !__ .-------------------•--..... e.11aw..sand &--grave.L, .A-12,0...white....sand... -._11-g �P _OF.Mgssq� -----------------------------------------gxaval--------------------------------------•-----•---•-----•---------•---•-------•------------•---...................... . REHWi6-K tiN U Nature of Repairs or Alterations—Answer when applicable.................................................................... Z...........2---__. CHAPMAN -------------•---------••-----...-•--•-----•-•---•-•--------•-•--...---•-•----•----.....................•............--•---..............-------••--•............--•---..... •.................... Agreement: .o I�No. 2765<, The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac the provisions of ilTl:;. 5 of the State Sanitary Code— The undersigned further agrees not to plxc th operation until a Certificate of Compliance has been issued by the board of health. - /--Signed 1 L yY =` { .......................... Date Application Approved By...... _•--- GC/�/.t.. ,.......................... --- -_7.F......--- Date Application Disapproved for the following reasons:................................................................................................................ ..........-•-----•--•.........::..•-•----•-•-----...---.......------......---------.....---•--------------•-........---......--....------•---•----------------•-------•-•-----•--------..........------ Date PermitNo......................................................... Issued-...................................................... Date SOIL LOG t I 3"i.10 , 2°.PEASTONE LOAM a FILL 12"MAX. / I .I r r'.. • e Ie O �..- JV4 1/� DIST. / �1°. O U ° '� C.1. •,BOX ° 5.<h 40� )35•10 1 mild. 1000 —�' °24''O1N.0 1000— GAL. °°o I �c 2G. i fss7 133 o GAL. 1 �'• PRECAST OR ° ° e I /M`r> Y I l"' - SEPTIC 6 I1 0 ••• BLOCK e ° I ��,.a E ,z.9u_ Z I�� � r. ° ° of thy•/® TANK • e SEEPAGE PIT (l It. = 470 6,4"71 4/ Aydr Flo D° I = 79 6-4 20' MINIMUM oo°• •o TOT b .54c) G.IL FOUNDATION I Y2 ff WASHED STONE Z ���aE 13y C,c�a�.�j• T1r�" `7—!,E 5^r Ee.,c.T`«.rc E • tgs,j�k 4V4. lot/ P E N C. RAT t DE�/6N A40W = 330 ; Ip4x fc��A� e t �a.2'cJfi'r'.y chs i��e• 20, 1ev77 TEST BY : H 1' >`1,��.fAl2—w ?o tea' Za+u�i.tC l �-�.��afa NO 4neliSrVeAr TOWN INSPECTOR: +�/"�1 Vm-tt is y of ' '�E `�isw�l A �' v.2avSTaa ,l�, rirf d� , '�� �E' Cl1`iE� BACKHOE OPERATOR : 1� TEST MADE ON : DANA c\ - v 1hl4 r O tp 1.7. 455P � ' 60 4/�� /ddp b�L• t 4 3Z;pr'Y4 T•' i Fi la , \,Vt� 137.5 11vv /36-ZA 7 �b*2ygcc� 0 .�_T' , { 3 Baeh-J. 27�6, • -----•--�•- S I t 1374 t`1 It r bti .-...�-....w..u....� .-.w...�,...... �.�,s..... 1 %..i...+�..lvw.,`•lv,.r..- .o_...�.�..+-+���O w.e.+.v-..+•y+-+-.r.. +.-•..-........._-..... _.`.� +"t •w, � " � �n. UitL' S. CHAPMAN f ELEVATION SCHEDULE 2'cl,q I=> Nu. 27654 PROPOSED SITE PLAN -.6, clsT,7 I. INV. AT FOUNDATION c �3�•Z¢ OFFS N ¢�\�� N - 2. INV. INTO SEPTIC TANK SEWAGE SYSTEM DESIGNIN 3. INV. OUT OF SEPTIC TANK - i35.82 /oT 46e, 4. INV. INTO DISTRIBUTION BOX = � 5' 1 SCALE: I 20, &C 19 77 5. INV. OUT OF DISTRIBUTION BOX = J35'�O� C-567r> 6. INV INTO SEEPAGE PIT = 134 2.3 CAPE COD SURVEY CONSULTANTS ROUTE -132 7. BOTTOM OF PIT = /28•Z3 HYANNIS, MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. 8. BOTTOM OF STONE LAYER = 1 {