HomeMy WebLinkAbout0038 LAURIES LANE - Health -38.LAURIES LANE
MARSTONS MILLS
TOWN OF BARNSTABLE
LOCATION �V ZaLar.'e-S Zn_ SEWAGE#
VILLAGE—Ai�`ST S A''G l S ASSESSOR'S MAP&LOT
INSTALLER`S NAME&PHONE NO.
SEPTIC.TANKCAPACITY /Oaa
LEACHING FACILITY-' (type)
Leo ekes (size) o?`
NO.OF BEDROOMS
BUILDER OR OWNER
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 Ieaching facility) Feet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Kimberly Miller ;
Property Address r•-,9
38 Lauries Lane `
Owner Owner's Name
information is Marstons Mills Ma 02648 2-28-18 -F
required for every -
page. Cityrrown 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. General Information { a 9
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return Name of Inspector
key.
Excavation
Company
�y Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 SI 13747
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2-28-18
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
""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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
(
Commonwealth of Massachusetts
x
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is
required for every Marstons Mills Ma . 02648 2-28-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System was in working order at time of inspection and was pumped after inspection for maintenance.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* 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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered: A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is Marstons Mills Ma 02648 2-28-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
E ❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (Actual) 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (gP ))�
Detail:
2016-61,000gallons 2017-74,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Last pumped 1 year ago
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Tank size
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 117
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
New SAS added to existing system in 2008
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'3"
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):.
Distance from private water supply well or suction line: Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000gallons
6„
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M yvevvw Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
30"
Distance from top of sludge to bottom of outlet tee or baffle
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank was
pumped after inspection for maintenance.
Grease Trap (locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M ,•�''a Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is Marstons Mills Ma 02648 2-28-18
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not
show signs of back up or carry over.
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.):
NA
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane .
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1 pit
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: (2)45'x2'x2'6"
❑ 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.):
Leaching was in working order at time of inspection. The leach pit was full and the trenches were in
working order with no high staining.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is Marstons Mills_ Ma 02648 2-28-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M Kimberly Miller
Property Address
P
38 Lauries Lane
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 2-28-18
page. Citylrown State Zip Code Date of Inspection
D. System information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Driveway
A Rear B
AC- 19' BC-46'
O AD- 66' BD- 90'
AE- 107' BE- 131'
AF- 85' BF- 106'
0
OF
V
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is Marstons Mills Ma 02648 2-28-18
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high round water: >15'
p g g 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: Permit date 1-23-1998
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M Kimberly Miller
Property Address
38 Lauries Lane
Owner Owner's Name
information is Marstons Mills Ma 02648 2-28-18
required for every
page. CityrFown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
e17
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage DisposalSystem•Page of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
38 Lauries Ln 0�% • o q d
Property Address
Integrated Asset Servicesyq
Owner Owner's Name
information is required for Marston Mills MA 02648 4-18-08
every page. City/Tovm State Ztp Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
A. General information
1. inspector: --
Shawn Mcelroy
Name of inspector
Upper Cape Septic Services r
Company Name t
29 Atwater Dr X-
Company Address r_
E. Falmouth MA 02536
Cityrrown state p Code
r
1-800-495-0905 S13971 CD �
Telephone Number License Number
LD M
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
TItle 5 13 10 CNR is,0001. Th,e Mm.
Z Passes ❑ Conditionally Passes ❑ Fads
� �ee�s�Uzil�es�valu�io�byt�i���1 App��is�t�A����
i 4-18-08
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
****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•03/08 Tim 5 Official nspe.ticn Form-Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is Marston Mills MA 02648 4-18-08
required for
every page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D -
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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 exfiftration 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
t5insp-03108 Tdie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M y 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marston Mills MA 02648 4-18-08
every page. C4frown State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cunt.):
❑ 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:
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.
t5insp•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection, Fora
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Flame
information is required for Marstons Mills MA 02648 4-18-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health(cunt.):
❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of.the analysis must be
attached to this form. ,
3. Other:
A,
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No ,
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
El ® or clogged SAS or cesspool
Liquid depth in cesspool is less than 6'below.invert or available volume is less
El ® than%day flow
El ® Required pumping more than 4 times.in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ " 0 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.
t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owners Name
information is required for Marston Mills MA 02648 4-18-08
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cunt):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim wellhead Protection
Area—WA)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.
t5insp•03M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 4-18-08
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ®, Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑' Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of.break out?
® ❑ Were all system components,.excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) 1310 CMR 15.302(5)]
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4M 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marston Mills MA 02648 4-18-08
every page. City/Town state Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 3-08
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp•03MB Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15
X, Commonwealth of Massachusetts
Title 5 Official .inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marston Mills MA 02648 4-18-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.) ,
General Information
Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (f yes, attach previous inspection records, if any)
❑ Innovative/Aftemative 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:
1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp•03/08 Tdte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
..�' 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is Marston Mills MA 02648 4-18-08
required for
every page. Cityrro`hn State Zip Code Date of Inspection
D. System Information (cunt.)
Building Sewer(locate on site plan):
Depth below grade: 24"
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
155,
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting,evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18"
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:
1000 Gal
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle 22"
Scum thickness 0
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
161,
How were dimensions determined? Tape
t5insp-03/08 Titte 5 O[frceai Irispection Forth.Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 4-18-08
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank in good condition with baffles in place.
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.):
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):
t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is
required for Marston Mills MA 02648 4-18-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cunt.)
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ' ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5ins 03/08
P• Title 5 Of6ce1 Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marston Mills MA 02648 4-18-08
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt_) :
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number.
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: : 2-43'x2x2.5'
❑ leaching fields number,dimensions:
❑ overflow cesspool number.,
❑ innovative/attemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Leach trenches are in good condition with no signs of failure. Leach pit is in good condition.
t5insp-03= Trite 5 Moral Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 4-18-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
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-03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is required for Marston Mills MA 02"8 4-18-08
every page. City/Town State Zip Code Date of Inspection
D. Systems Information (cont.)
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.
SalC fY�
A
L'D
Or=
t5insp•03(08 title 5 Ones inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M y< 38 Lauries Ln
Property Address
Integrated Asset Services
Owner Owner's Name
information is Marston Mills MA 02648 4-18-08
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 30'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked date of designIan reviewed:
' p Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
® Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'. USGS shows water at 30'.
t5insp-03108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
Op THE 1p�
Regulatory Services
I MSTABM ; Thomas F. Geiler,Director
A,f1639.p3,�p Public Health Division
Thomas McKean, Director a
200 Main Street, Hyannis, MA 02601
Office: 508-862 4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original /coPY of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF BA'RNSTABLE
LOCATION SEWAGE # �O
VILLAGE ASSESSOR'S MAP & LOT QL� - G
INSTALLER'S NAME&PHONE NO. T P
SEPTIC TANK CAPACITY MdC )ADn �1
LEACHING FACUATY: (type) /� dEd W/�t /(size) d2 X Z �
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: ' �•�J ' 1 COMPLIANCE DATE:
Separation Distance Between the: 4—
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ' 34) 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 o acl cility) A,/--� Feet
Furnished by �'
d
71
11
y
No. Fee
THE COMMONWEALTH OF MASSACHUSEr VS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Mtgaal *pgtem Construction 3dermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Iodation Address or Lot No. Owner's Name,YdresTel.No.
Assessor;,lylap/Parc 1 M P_ 9
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
T(e
'?CL,�
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 �eyb 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) -//,3 X .2-k,;Ll Zt
Z_
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 it of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by this o d of H
Signed / G`"da Date
Application Approved by Date,`-,2' -'��✓
Application Disapproved for the following reasons
Permit No. Date Issued `r
No. �� / Fee L+i o ...
THE COMMONWEALTH OF MASSACHUSET S Entered in computer:
Yes -f
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
ZIpplication for ;Dioogal *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components
3o n/ddress oQ r L_J Owner's ate, ddres�L`Arl.N
Assessor' ap/Parcel
MP- 'i�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
SIB
3
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 �SYQ 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) Z.,_4y� � -- X Z � Z1 4t
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 it of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by this o d of He '
Signed �yG•,��-^e�--- Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued J"_ i17;7 1'
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by
at 39 a—u_-LAl has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ^', dated f
Installer S,//,%_ e�®/t 'a/ Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
No. f U/' ---------------------------Fee "'►a ,C�-��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migpool *raem Congtruction Permit
Permission is hereby granted to Construct( )Repair(,(<)Upgrade( )Abandon( -
System located at 3 F � ,t y G G .. .e,4" am /1Z )�6
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of th'. it.
,,
Date: 9.! ,`" ` 7 Approved
` IOV9N1
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CER
TIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
ion J, � � ��_ , hereby certify that the applrcatro for disposal works
construction permit signed by me dated
concerning the
/ w meets all of the
property located at
following criteria:
e There are no wetlands located within too feet of the proposed leaching facility
e There are no private wells within 15o feet of the proposed septic system
e There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
e If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will Bpi be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) 23
DATE:
SIGNED:
LICENSED SEP C SYSTEM INSTALLER M THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also irthe licensed Installer posessea a eerttfled plot plan.
this plan should be submitted].
q:health folder:cert
a 2- - Y� fry x e2 � � -sue
TOWN OF BARNSTABLE
LOCATION �� �'� SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. T '
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) AM y3 (size) A k Z
NO:;OF BEDROOMS _=
Bt IILDER OR OWNER
PERMrrDATE: 3 9 COMPLIANCE DATE:
Separation Distance Between the: 4.
Maxi um Adjusted Groundwater Table and Bottom of Leaching Facility Feet
m*
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
;within 300 feet o aclt>)n cility)
Famished by �' '
X �;h
r
ASSESSOR'S MAP NO. ,. PARCEL
LbCATION
S SEWAGE PERMIT NO.
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INSTALLER'S NAME i ADDRESS
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s UILDE R OR OWNER
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DATE PERMIT ISSUEDla-3 lk4
DAT E COMPLIANCE ISSUED Z�
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
170.1.W-N................0F.13ARKETAbLF....................................
Appliration for Disposal Works Tonstrudion lirrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
...M,..Mj.�LS.... ..........................................................................................
Lal�o'. d�d. s� t 0 ARK3:r_A.1b11- '01' . &6--Obt...Wo..IOD---WE31...tAAK.S.5...HMAN.wls
. . ...... .. . .................................. ..N.. ... ..HARN CH
Installer Address
Type of Building Size Lot.Q4 ... Sq. feet
U 3 ...
Dwelling—No. of Bedroor4k..........................................Expansion Attic Garbage Grinder
P4 Other—Type of Building KE.�S,............. No. of persons............................ Showers Cafeteria
44 Other fixtures --------............................................................................................................................................
44
Design Flow.........1_5�` ......................gallons per person D-err/day. Total il�;flow---�.5.30.....................,.VlonsW .
Septic Tank—Liquid capacity/ Length.,B --- Width..... Diameter________________ Depth_... ..........
Disposal Trench—No_ ................ ... Width____._.__.._._______ Total Length.________..__._... Total leaching area...................sq. ft.
Seepage Pit No..ON-E------- Diameter.....�2........ Depth below inlet._._- .... Total leaching area2.03..sq. ft.
Z Other Distribution box Dosin
Percolation Test Results Performed by. ......................... Date..... .......
Test Pit No. I....c>2......minutes per inch Depth of Test Pit____________________ Depth to ground water..N_.
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit___.._._________.__. Depth to ground water._.._-_____._________...
P4 . ....................................................................................................
0 Description of Soil........0- . ... ..............................................................................................................
....................................... . .. ................................................... .........................................................
U
---------------------------------------- ......................... ................................................................................
U Nature of Repairs or Alterations—Answer when applicable............................................ ...................................................
..............................................................I.........................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'L I TL IE 5 of the State Sanitary Code—Pe undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i by th oard of health.
Signed____ ...... . ....... ...................................................... ................................
Dat
Application Approved By............... .............. --------
.............. ........................ .......................... .....
----9-r Vate
Application Disapproved for the following reasons:...............................................................................................................
.........................................................................................................................................................................................................
Permit No. 5�6— ... .49 Date
. ... ............................. Issued.......................................................
Date
—--------- --------------------------------------- -
PIP s a
Fizz.." .....................
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD OFHEALTH
Appliration for Disposal Works Tonstrurtion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
+......--`:......_. . !k.....`...... ' i........ ............. . ----.......----------..................---
Loca io /-Addr ss r ii ! ``
1 �..�... ��.!... ` 1 o Lot No , J � I_
�.._..
Installer Address Ic
2
U Type of Building Size Lot.::- Clz_�._...Sq. feet
1.a Dwelling—No. of Bedroom ................... ...................Expansion Attic ( ) Garbage Grinder �Vb)
�'_l Other Type of Building _ ............. No. of ersons...._................__.____ Showers `
,— YP g •-��-=••-=- P ( ) — Cafeteria (�
dOther fixtures -•-•••--•••-•-------•--••-•-•-•--••------•-•--•---•-•---------••••......-----•-•-•----------•---
W Design Flow........ .......................�^� gallons per person per day. Totaldaily flow__..A- �._2...................•..,.gallons.
WSeptic Tank—Liquid capaclt}�!--:[,: .gallons Length .:`s._.. Width._---_._.�._ Diameter________________ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
'7
� Seepage Pit No����_�._....... Diameter.._.A_�-•........ Depth below inlet..... Total leaching area: •:.C==_...:....sq. ft.
Z Other Distribution box (�,j Dosing tank ) ,
a Percolation Test Results Performed by_ � .�... .._:..% ` _ � .�........................ Date.................. %........
a Test Pit No. .......minutes per inch Depth of Test Pit.................... Depth to ground wateIr.
f? Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate.........................
a .. ................-------•---•--------•-------•.........................•------...--••- ...
Description of Soil......- a `
x I -Z4 C I r=1 1 �i,t+`)
rJ ------•. --•-•--•-• ..-- --------------------------------------------------------------••-•--
-
-------------------------
UNature of Repairs or Alterations—Answer when applicable.........................................................................................
.................................................... -----•-•-•--•-----------------........-----••----......----------------------------------•-----------------•-----------------------------...------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITU 5 of the State Sanitary Code— 7e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been-• by th oard of health.
Signed•-• ---.. ....... ._ ............................................................
Da
Application Approved BY............... _ �... '. ---- ......------------........--------- �' ....6.........
bate
Application Disapproved for the following reasons---------------•----------------------------------•-----•------------------------------------------.....---------
----•...---------•-----•------••---------------•-----••-•--••----•--•-•--------••-•--------------•-••------••-••--•---•------••----•-----------------------------------------------------••-----------
w
te
PermitNo....�..... .................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS {x
BOARD OF HEALTH
TA
Trrtif iratr of ToanpliFanrr
THIS IS TO CE EY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ..............•-- =�-�-. l ••. -:.--•--•-
I taIter
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.... :__ 474 Q1........... dated.....i�_ � 6----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GARANTEE THAT THE
SYSTEM WILL FU ATISFACTORY.
DATE.................................. ... . :3.� ..-----...-•-- Inspector...--�.................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,' .. OF...............•----................................................................
FEE...
Disposal p o=ks Tonstrudion rrntit
c Permission is hereby granted t
..... -• -•---------------------•---•-•--•-••------•--••--••••••-••••-•---••--•--•••---------•------.................._..
to Construct ( ) or�Repair ( ) an Individual Sewage isposal System
at No............ 1. fl -rn�..
Street - 1 � -�i
as shown on the application for'Disposal Works Construction. Permit N ' �(?�� t'
Dared- --------•• •--••----------------
fC Board of Health
DATE............. fir--------` ------1------------------------•----
FORM 1255 A. M. SULKIN, INC.. BOSTON,
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TOP OF FOUNDATION
' CONCRETE COVER
CONCRETE COVERS
4"CAST IRON 12°MAX.
OR SCHEDULE 40 12"MAX.
' P.V.C. PIPE 4 SCHEDULE 40 P.V.C.(ONLY)
� PITCH 1/4"PER.FT. PIPE- MIN. LEACH
PITCH 1/4"PER.FT. PIT
°• ° PRECAST
INVERT LEACHING
:.�
''� ELXr/, INVERT INVERT p . e•; PIT OR
DIST. EQUIV.
GAL
SEPTIC TANK
e . ELS.�..{-�.. . .. BOX ELY.`(Xl... • : � >_ �
'ee ELEL.. Rf /.�. D . .... . INVERT a ►=F- '•�'
•`� ELY.Il3... INVERT w w 3/4"TO 11/;
, ELy/!rQ : �q WASHED
"D o
�'� .�S ---►i---6 0 DIA.
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o.°• ' ' I _ — • DIA:--+� IyI
PROFILE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE .
/�$OI L LOG ` WITNESSED BY :
DATE .`l( /. . . ..... TIME.. . . .... C� l�E . . BOARD OF HEALTH E LTH
TEST HOLE I TEST HOLE 2 ELEV , , , , ENGINEER
EL-EV..51.X.0. . . . . . .. .. . . . . . . . . . . . .
0-� o oltf--- . . . . . . .
DESIGN DATA :
NUMBER OF BEDROOMS 3
TOTAL ESTIMATED FLOW , GALLONS/DAY
BOTTOM LEACHING AREA . SO.FT. /PIT
SIDE LEACHING AREA . . . 1�10 . . . SO.FT./ PIT
GARBAGE DISPOSAL . . . ..(50% AREA INCREASE)
TOTAL LEACHING AREA SQ.FT
PERCOLATION RATE (C;s 5 MIN/INCH
LEACHING AREA PER PERCOLATION RATE .. SQ.FT.
��.WATER ENCOUNTERED
NUMBER OF LEACCH'�I G PITS . Q���
APPROVED . .. ... . . . . . . . . BOARD OF HEALTH (,34�= //3
- DATE. 2,��H G:� 4 !.�?�i.,�',�,-• /SD�.,;:�; 37,��6�/% �/�<_
jo719.4 -
AGENT OR INSPECTOR
'j)F USE 3�CT 9de:-'�° k/SE'1Q Ep`�N OF 4,4X <'s
o c -k PIT ���� e,yG
ACO
gNATAR
PETITIONER": J •i ��o ''�.