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HomeMy WebLinkAbout0129 LONG POND ROAD - Health 129 Long Pond Road Marstons Mills A= 013-044 I i No.. d z_0 1�0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppfitation for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(Xj Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. I Xj LoV& p00'0 R) Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ` MM �� �� Installer's Name,Address,and Te.No. C,&-q7,7—g8'77 Designer's ame,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms (1� I�" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided �/TJ�� gpd 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) j 14—t6 D40L f 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 Certificate of Compliance has been issued by this Board of Health- Si Date ✓t'�" .Application Approved by - Date .Application Disapproved by Date for the following reasons Permit No. Date Issued I f No. d U Fee_7 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWNOF BARNSTABLE, MASSACHUSETTS s r ZippliLation for Misposar *pBtim Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System )(Individual'Components dg.A Location Address or Lot No. 1 ;9 L,©L)& pcu-0 PZ) Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q HM k2nN C� �NS Installer's Name,Address,and Te.No. a&-q7.7-8877 Designer's Name,Address,and Tel.No. Type of Building: F. Dwelling No.of Bedrooms J IA- Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) OA: gpd Design flow provided A /1/ gpd 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) 'T_U-CO)411 )(_10D40) lD TlZ/SE'.]D R 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 Certificate of Compliance has been issued by this Board of Health. r Si = - bate Application Approved by Date Application Disapproved by Date " for the following reasons y Permit No. i�� I'n d Date Issued --------------------------------- --- =- - ------------------ ` t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by � n t )p du ,at f�p� �1 ]� �C�/ has;beeii constructed in accordance. with the provisions of Title 5 and the for Disposal System Construction Permit No. d Ld O dated- Installerj _ �) J�' ���_(' Designer #bedrooms N 1 Qpproveddes tl�low k/1A gpd -The issuance of th' permit Ishall not be construed as a guarantee,6t the syske 'll fimbtio, as design r Date rr �] Inspector ( 1 s 0 - , - = - - _- -------= -- - -- r - - - - - - - �t "�, No. o 1 v_ 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction Permit 'Permission is hereby granted to Construct( ) Repair(�O Upgrade( ) Abandon( ) System located at w& '' `` and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date r ! ? /Z d Approved by c�,, r�S � l n-e de d � � r � C-7 � � 4 7Y C/o 6/y) Commonwealth of Massachusetts 4 ot& - oq f Tale 5 Official Inspection For m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long pond rd u� Property Address r, Ronald Mansbach Owner Owner's Name information is Marstons Mills Ma 02648 5-21-20 required for every 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 Important: A. Inspector Information �,/ 46au filling out forms � 1 on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites path re6 Company Address South Yarmouth Ma 02664 City/Town State Zip Code retwa 508-477-8877 S114430 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 OF�Mgss 2. ® Conditionally Passes MICHAEL`yN? '0. S :�= 3. ❑ Needs Further Evaluation by the Local Approving Authority =_o• SEAR . *: No.SI14430 4. ❑ Fails �'r'�FRTIF�� 'off;. /S'i N SP`E��O`��• 5-21-20 Inspector's Signa re Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 129 Long pond rd Property Address Ronald Mansbach Cwner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 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: ❑ 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: 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 Title 5 Official Inspection Form W- �Ia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town 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): D box walls are gone needs to be replaced ❑ 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 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town 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, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: m Failure Criteria Applicable to All S 4) System pp stems:y 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 t5irisp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Long pond rd U� Property Address f Ronald Mansbach Owner Owner's Name information is Marstons Mills Ma 02648 5-21-20 required for every 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply ❑ ® well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. EJ ® 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 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with 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 p Title 5 Official Inspection Form i1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long pond rd u Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vic, !% 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 2 Number of current residents: 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)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is Marstons Mills Ma 02648 5-21-20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type:of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ 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: feb 2020 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........... 129 Long pond rd u� Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system El Single cesspool ❑i 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: 2nd 1000 gal pit D box 12-14-94 #94-725 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts I`o Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is Marstons Mills Ma 02648 5-21-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) 1000 Gal 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 411 Sludge depth: 24" 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 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Budge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both covers are at 8" below grade with both inlet and outlet tees in place t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... 129 Long pond rd u Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑_other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene —],other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Long pond rd V Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x21 and walls are gone, box has 2 outlet pipes and is 16" below grade Needs to be replaced l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Long pond rd v Property Address Ronald Mansbach Owner Owner's Name information is Marstons Mills Ma 02648 5-21-20 required for every page. City(rown 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: 2 ❑ leaching chambers number: ❑ 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is MarSt0 ns Mills Ma 02648 5-21-20 required for every page.e. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2- 1000 gal pits, orignal pit is dry and clean, new pit has 2' of water No-sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Dept-i —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.): l5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is Marstons Mills Ma 02648 5-21-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts ,r Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form Not for Voluntary Assessments !%F" 129 Long pond rd u� Property Address Ronald Mansbach Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 4 sk �_ �l 0 A lbo O f3 etc 11 C3 �rj N -�v o 1 d st �, Did j, t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts T� Title 5 Official Inspection Form Ii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^ � 129 Long pond rd t,— Property Address Ronald Mansbach Owner Owner's Name information is Marstons Mills Ma 02648 5-21-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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) ❑ 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: groundwater determined by Town of Barnstable groundwater contour map 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 Commonwealth of Massachusetts �� .. Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 129 Long pond rd Property Address Ronald Mansbach Owner Owner's Name information is Ma 02648 5-21-20 required for every Marstons Mills page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH VINCENT P Owner Owner's Name information is Marstons Mills Ma 02648 11/18/2013 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. I fling out f When A. General Information filling out forms on the computer, use only the tab 1. Inspector: I key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. ICI Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/18/2013 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. (1/0 � 1 1 / t5ins•3/13 Title 5 Official Inspefnrm-- bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name requiredred for every information is Marstons Mills Ma 02648 11/18/2013 required 'I page. Citylrown 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: The dwelling located at 129 Long Pond Rd Marstons Mills is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 precast leach pits. The system was found to be in proper working condition at the time of inspection. 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): t5in:•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is Marstons Mills Ma 02648 11/18/2013 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced El Y El N E I 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 i 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 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 page. Cityrrown 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 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is Marstons Mills Ma 02648 11/18/2013 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 11 ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 page.e. CityrFown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Yes No P ❑ Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M e`' 129 Long Pond Rd Property Address SMITH,VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 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: original system 1979, leach pit added 12/14/1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons 6" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is rec wired for every Marstons Mills Ma 02648 11/18/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑,concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•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 M 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 page. City/Town 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" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•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 M 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): newer leach pit was opened and found to have 1' of standing water with no sign of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•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 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/18/2013 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 t J Z A-i Z<<3 3 A-Z 32 ti Aj 3i H3 6 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is Marstons Mills Ma 02648 11/18/2013 required for every i page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam:. ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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) ❑ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. 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 4 r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 129 Long Pond Rd Property Address SMITH, VINCENT P Owner Owner's Name information is requires for every Marstons Mills Ma 02648 11/18/2013 , page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5in3-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 M �1 TOWN OF BARNSTABLE LOCATION J SEWAGE # 1 - j_ VILLAGE ASSESSOR'S MAP & LOT r INSTALLER'S NAME & PHONE}tNO.. °(Z� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ,k)Q,,,) P 1°1 (size) c )(6 (,t)a F1 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER d DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� � � 3 � � ��� � s� '� g � O�� � �, p �dx �1 � �v �fso� �`� S� � � �t� P�'� �� �a � N�� P`� �Y Q �° N� y� � 5 � '^`� ' � � r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiun fur Diti-pnittl Works Tunitrnrtiun Prrntit Application is hereby made for a Permit to Construct ( ) or Repair (1-V^ an Individual Sewage Disposal ... atR .l.t-•••-•-••••................... ....... ........................................................ L cation-Address or Lot No: � � -------------------------------- 4` � . � j._.�- .e�.. rL - fn, �' `�j ` Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-__-----J___________________------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.---_---__---_-_-__---..---- Showers ( ) — Cafeteria ( ) a' Other fixtures -_---------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 W Septic Tank—Liquid capacity./00_0 gallons Length................ Width-__-_-_..._--.-- Diameter....------------ Depth................ x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area---_--_--.----.-----sq. ft. Seepage Pit No-----------_-------- Diameter-------------....... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 93, Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ 1:4 ---••--------•--------------•••••••-•-••-•••-----•••---•-•--••-•-•-•-----•••••............-•---•----...............••••--...••••-•-•••••------•--............ 0 Description of Soil........................................................................................................................................................................ x V ........................•-•--•---•--....----•-•--•---•---.......-•-•-•-•--•------.....----------.....--••----•--------------•---------...---.....--------•-------••--•---•------••-••-••••----•••......-- W -----------------------------------•------.-.-.----.-------------------------------------------•.------- r ......... ` U Nature of Re air or Alt tions—Answer when applicable.._.___ ..._..._!____.____��C�cz....... t .._ C'�".... ------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl' as be yliy7he board of health. ` Signed ----- ----- ------------ ---- ................ . ...................... I �. ..� ..... Dace �...... Application Approved By ............. /�......�-�/....e-���� Application Disapproved for t e follow' g rea.tonf: ................................................. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ------------------------------- q Permit No. ........ ...� .- ............. Dare .. Issued ............ ...-..�1..L -..F.-.-Y.......... Dace U(4 Fmc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diripuuttl Mirk,i Tunutrnrfiun liPrmif Application is hereby made for a Permit to Construct ( ) or Repair (VI-an Individual Sewage Disposal System at: ..r ..t....<a� ... c� CZ�_ ------------------------- ------- ........................................................ cation-Address or Lot No. a ...... \ 1 .R/ .n--------------------------------------------- - -�` P..uV ----- os U l- -----• Hy lJ` 'V Installer Address UType of Building 3 Size Lot-----__:-------------------Sq. feet Dwelling—No. of Bedrooms-------- ----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QOther fixtures ------------------------------------------------------...------------------------------ .............................................................. W Design Flow............................................gallons per person per day. Total daily flow_.._________._-_---__._....................gallons. WSeptic Tank—Liquid capacity_Q)J0galtons Length---------------- Width___-___..._____- Diameter_---.._._-___.__ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------- -------------••-------•-•---••--------•-•-----•-••---•-...----•_. Date........................................ a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ pa' ------------------------------ O Description of Soil....................................................................... 11 U --••---•----••••••-•----••--•--•-•••-•-------------------------- 'c. UNature of Repairs or Alt cations—Answer when applicable._.__.AJ.�_______�........�� .......�Q�.C-.t/i'.._F(�"___. ..... ••Ia...... . .....-----•------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasbe�e y ehe board of health. Signed .... �''.`� ...... .--. _ � ..V.r r Date 1-- Application Approved By ............... . a �wvr ........_..._..................-- ........ ................�.../------��{ �e � Application Disapproved fort e follow' g reasons: --------------------------------------------------- -- - ------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------- ----- -------------------------------- Permit No. .........L...Lf---------- 1------------.--- Issued ............/.?,. ../---L(...-�T... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#ifi a e of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by-------------------- . -----.....-------------------------------------------------------------------------.......-----------------------------............------------------------------- m,tan at ..........1 -------(.._ �- --------- 0(��J--------- ------------M-- ------------._..............- -------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..._?V_,..7Q2...c,.:.:... dated .._../... ..-.�.. .-..���.�... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... .. r Inspect r �-�i-r ---------------------------------------------- - -----_------ ---•- THE COMMONWEALTH OF MASSACHUSETTS `� / 5 BOARD OF HEALTH q TOWN OF BARNSTABLE FEs..... ...?.......... �i��nunl Turku �un,��riun Vrrutit Permission is hereby granted- ..:..........•_-----__ V`- --- ----------•-••-.•--•--••-------------•-•-----...--••••......-•--........... to Construct ) or Repair J an Individual Sewage Disposal System at No...... � [_Gn --- .... -.... M ,......... Street as shown on the application for Disposal Works Construction Permit No.A :-Zi__Dated-_-.-_ /�- �' -...� _ f `� Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS LOCATION /a SEWAGE PERMIT NO. VILLAGE , IN_" A LLER'S NAME A ADDRESS U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Z2- _ �2_�d I f /® f e �h No:._9...q1....... Fia....%l l... THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF ,_HEALTH ...................OF...... /�7.. .. ��. ....._........:.............. App irFation for Diipos al Works Tomitrurtion ramit Applica 'on is hereby made oror a Permit to Construct �or Repair ( ) an Individual Sewage Disposal System ,�zY _.. onr..D.......R .P:._._....M,rP.&5ng4..S. M-«� s..................... o.%...�1 ............_.._...__..........._. -• .Locatio A r s O Lot No. r Address O ner ................................ Installer Address d Type of Building Size Lot., ........ ......Sq. feet U Dwelling—No. of Bedrooms...._....��__..............................Expansion Attic (Vo) Garbage Grinder (Iva) Other—Type T e of Building Al/14.........._. No. of persons............................ Showers — Cafeteria Pa YP g ----- - - P ( ) ( ) a' Other fixtures .................................. ----------------------------------------............------------------. ----•------ W Design Flow.........Z/. ......•................gallons per per day. Total daily flow.......-3_30' ......................gallons. WSeptic Tank—Liquid capacity/Ar?�4t-.gallons Length4q_._�.... Width..!' O."'. Diameter................ Depth-..!L27.`:_. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../----____--. Diameter...47. .......... Depth below inlet....6........... Total leaching area. C?_0...sq. ft. Z Other Distribution box (e_.� Dosing tank ( ) aPercolation Test Results Performed by....R01Ua4j�,D.....tQr___. lFt a __R: , Date_.Z E ..... Test Pit No. .._._minutes per inch Depth of Test Pit._ ` .......... Depth to ground water..!d..ate...,__. LL, Test Pit No. 2.,4_..-_..minutes per inch Depth of Test Pit...l.Y... ........ Depth to ground water_Na/l-0.__.__.. a -•--------•---------••-----••--•-•-•----•---------•-----------------------------•----•---•--•--••-•.......................................................... O Description of Soil-•----1- -'--` -r---L� +/. ....... .G.a5ioi-.e _A 7------- C4,4&s-C--------�� ).................................................................... .._.5t_Ae3-!_L-!1/L........$',a.!L,,..... ........Y�------47 e�h'--------.l..C��7 .._.rYQ�-�-r,S.................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ................................................... /,� . -- Agreement: K/Fi�l ��. _ �Z 213—7 �- . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si ----•----------•--•-•--• ----------------------------- ---------------.------- ""Dat Application Approved By llil _'_ 1 --7 =---------- Date Application Disapproved for the following reasons:--- ------------------------•-•-•-----••------------------------•----............-•----••-•_.... .......................................-•---------------------•-•---•--•--------------.......---------------•---------••--------•-•------•-----•-----------------------------------------------......._ Date d Permit No......................................................... Issued..1.2_`..-.1 e Date- ' r' No. 9. �..._ F�$..... S�.` � THE COMMONWEALTH OF MASSACHUSETTS ;* BOARD OF .HEALTH h� /....G�.1V...................OF...... ... L�a►11.. } L':1 .. Appliration for Disposal Works Tanstruriiun Prrmit .0 Application is hereby made for a Permit to Construct (t/) or Repair ( ) an Individual Sewage Y Disposal System at: !�-�. ... lY.. ?....... = •---••-•. a s ......Locatio A �d s J f v3 •1 � 0Yf Lot No. tf �M/ f ► • - -' ..... .... .......... .. -- ....•--.......................................... / ..._......._._...... W Ll�p l���rOvner Address a --•._....�__...._...--•••-•....-•-•-•-•-------__._a........•-•.............................. ...•-._...__..................•--...................._.._.___.._.._.._.__._....................... Installer Address Type of Building Size Lot._-'q-Z 6 a--..Sq. feet U Dwelling—No. of Bedrooms.___.___r�_____________________________Expansion Attic (mod) Garbage Grinder (•t►v) `4 Other—T e of Building ^J�eg............ No. of persons............................ Showers a —Type g ---- --. . . ( ) — Cafeteria ( ) dOther fixtures ......................................................... --..........•. . • --- --------•-•............................................ W Design Flow.........Z! .......................gallons per j& p'er day. Total daily flow.......__" "�y* �......_.......__."....gallons. -W ° Septic,Tank=;Liqu d capacity/00P..gallons Length .`:.`" Width.. .lP `Diameter................ Depth_.S.. y`.. x Disposal Trench—No. ................. Width.................... Total,Length............................ Total leaching area....................sq. ft. Seepage Pit No......../........... Diameter... ........ Depth below inlet....6.. ........ Total leaching area.ez_042..sq. ft. Z Other Distribution box (✓) Dosing tank (: .) `-' Percolation Test Results Performed b4� :1.>..... r y tlA..*04. Test Pit No. minutes per inch Depth of Test Pit X!?.......... Depth to ground water..J,rfn..e-____. (s, Test Pit No. 2_.4..2.<.....minutes per inch Depth of Test Pit... c!. ....... Depth to ground water_/V&!V.e....... --- --- --------------- ........_..................._._...._.._._.--•--•----••.:__._._.......---•---•-----•...... O Description of Soil......CJ«. � ' t'r,04.Afr ��j� 1�' . �'��.��--------�~ � ����991�S_G -"-5' W...4 D t �EQI G.. ••--4..:= � ..:./!,1. �, t fs'1 - ---"-""--".'9rv+ "--------".......--""""....................""""--.... W �'�1►s-rr�tk �„�. �nz r-7. r ;ST tc.44e�"--"........--""""-""--......"""""". UNature of Repairs or Alterations Answer when applicable................................................................................_......._._._.. .... .... ._..--• _--•................ . ... .• - Agreement ,.. .��'• 7 The-�,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT:., 5 of the State.Sanitary.Code— The undersigned further agrees not to place the system in operatn until a Certificate of Compliace has been issued by the board of health. Si . Date Application Approved By_.....,, _.eft -*•"--""-"" r` Date Application Disapproved for the following reasons: ........, -" o .......... . ............................ w>.....". 'S...................................... ............ .......... ....................... .1+........... .......................... ........................... Date PermitNo......................................................... Issued............................... Date THE,COMMONWEALTH OF MASSACHUSETTS BOARD HEA T ............. r t (9rdifiratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired Rom, by ^•• Installer: ..................... .... ......_............. ........_ ..•.......... rf, at. •.°; ..__ �- Y has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. ,.__ ........:.:...... da.ted_.. _.'_.r?:.d�. . ' ........_...... THE. ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILLr.FUNCTION SATISFACTORY.` ti DATE..............f. Inspector.,::fl ' ---"-"- -- - ............................. L. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...f,4 �.......OF..... �...��,rffd .................................................. ----• FEE....-.................. Disposal Vorks TOnstrnr#inn rrntit Permissionis hereby granted........ ................................................................................-............. :................. ..---- to Constr t i or Re it ( ) an I ivid}�al Se�%ag Disposal Syst 11 Street as shown on the application for Disposal N't ks Construction Per ' No... __ ___'. ated.._sZ ,.......... Bar f Health DATE........:... ............. ........................................ FORM ~'1255 HOBBS & WARREN. INC.. PUBLISHERS + ?s J. V Ba: G p t . -TEST ' HOLES '� 4 EXIST, LQT 1' 1/� F€C3, J t , t , '�E't,L 3 / GC?' 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