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Home My WebLink About0254 LONG POND ROAD - Health 254 Long 4 a Road. -P1 1 -r+ r Marstons Mills _ 1 A= 029 003 r t i S I Ci � n F ' 4q No. 0 �(� Fee J BOARD OF HEALTH / TOWN OF BARNSTABLE f- C � 01ppYicatiou _for Yell Cou!ftructtou permit Application is hereby made for a permit to Construct/( ), Alter( ), or Repair(vr an individual well at: Location-Address Assessors Map and Parcel L, , F,H N as v �o Ao..j R� �,a isT.r,,s ^4 1h Owner Address e-iv.v;s Crl Sk-a L.c d,oss Rai maIAeee ^4&, ooc. yl Installer-Driller Address Type of Building Dwelling .� Other-Type of Building No. of Persons Type of Well y " Pv Capacity Purpose of WellQee4es7%c tya7e/ �ep�t1cante..ti� S(-Me— I„c« Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of C:::��fias been issued b the Board of Health.p Signed D.,6 , y 8 a 3 A n Date 2 Application Approved By Dale Application Disapproved for the following reasons: (� Date Permit No. -VJ ao 13 -0 f d Issued �/I Date ----------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired by Ot.+riuiS 4 StiiwA, Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private W 11 Pr tection Regulation as described in the application for Well Construction Permit No. W2c 43 0� " Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. 0 — Or Fee y� BOARD OF HEALTH TOWN OF BARNSTABLEc 01ppricatiou jfor Yell Con5tructiou Perron Application is hereby made for a permit to Construct( ), Alter( ), or Repair(,,)' an individual well at: J S cf L /? 1 7 Location-Address Assessors Map and Parcel Owner Address Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well 1/ " /J Capacity Purpose of Well - r � Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed lo 11 Date Application Approved By r 6 ! Dae Application Disapproved for the following reasons: Date Permit No. '+ICI)o 13 Issued 14h 6 tj Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private W ll Protection Regulation as described in the application for Well Construction Permit No. IN?O 43-01 Dated .26 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL i SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Very Cougtructiou Permits�/ i No. (rJ I Fee Permission is hereby granted to Installer to Construct( ), Alter( ), 1 or Repair(*-)-- an individual well at: No. 0 �,wcj " ! _ l %L1 k Street as shown on the application for a Well Construction Permit No. L^') a 3 /(Dated .2d / Date ( Approved By JL TOWN OF BAR�N,SQTABLE LOCATION �1 L�z'1 ��cQ �G.Y Sow;aE# 'w u VILLAGE I ASSESSOR'S MAP&PARCEL 'S NAME&PHONE NO.' psi r X kdco n SEPTIC TANK CAPACITY 000 / LEACHING FACILITY:(tyype),�?E I- (size) 1000 gem NO.OF BEDROOMS .2 OWNER j �1 ►'1 —J� PERMIT DATE: C@M2=A=E DATE J-�5P 9 11 10 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet FURNISHED BY / "� f J ! I J ! ! J f J I I J f I f f f \ \ 4 \ \ ♦ \ \ \ \ \ \ \ \ \ \ \ \ \ G`t n A 22 72. ' Clean 5 . . . . . . 7 Jtility 'oles Dri ewaj.: - TOWN OF BA S BLE VOCATION C71 54 CiOnQSEWAGE# V,"1LLAGE f f , //,f AS SSOR'S MAP"&PARCEL O�cl 04- 3TAttrk'5 NAME&PHONE NO. //G� ( �(_o�snP_j� lJW fjW SEPTIC TANK CAPACITY oo 1 LEACHING FACILITY.(type) 7 (size) (o NO. OF BEDROOMS OWNER PERMIT DATE: GQ�_ /DATE: �3 /3 0 Separation Distance Between the: /7 H4 V POL d;J Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY f 2 a ;II more than 0'from SAS 1 1 f f 22 �, 5 °�s �Cleanout a utility , » 28 { Poles t 70 1 �DNueway� , 1 � M� s t I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills required for MA 02648 September 17, 2010 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. Impotent When filling out A. General Information forms on the computer,use 1. Inspector: v only the tab key to move your Patrick M. O'Connell cursor.-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mllls Cityrrown State O ate p Code 508.428.1779 S112855 i? Telephone Number License Numb SEP24RECD B. Certification 1 6 By 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 September 17, 2010 Job# 10-223 In pector's Signatur 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal ystem age 1 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Long Pond Road Property Address John Finn i Owner Owner's Name information is P required for Marstons Mills MA 02648 September 17 2010 every 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: Tank scheduled for pumping following inspection, leaching pit had 8-10" of effective leaching. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17, 2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•09f08 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 � r 254 Long Pond Road Property Address John Finn Owner Owner's Name information is P required for Marstons Mills MA 02648 September 17, 2010 every page. CityrFown 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 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•09108 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 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mill's required for MA 02648 September 17, 2010 every page. City/Town 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•0908 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 254 Long Pond Road Property Address John Finn Owner Owner's Name information is P required for Marstons Mills MA 02648 September 17 2010 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins-09108 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 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17, 2010 required for P every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: I Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A Well Water 9 ( y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. 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•09M8 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 wM 254 Long Pond Road Property Address John Finn Owner Owner's Name information is p required for Marstons Mills MA 02648 September 17, 2010 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17 2010 reeuired for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date 3/18/87 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' 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.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 6" t5ins-09/08 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 ..''~ 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17, 2010 required for p every 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 24" Scum thickness 4" 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 9" 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 scheduled for pumping following inspection. Tees were intact and liquid level was found at outlet invert. 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 15ins-0948 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments µw 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17 2010 required for p every 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: 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 15ins-09108 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 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17 2010 required for p , every page. Cityfrown 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.): 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•o9im Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form �s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17, 2010 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Liquid level in pit was 8" below inlet with no high stains above current level. 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 15ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '( 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17, 2010 required for p every page. CityrFown 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•09108 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 ` Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Long Pond Road Property Address John Finn Owner Owner's Name information is required for Marstons Mills MA 02648 September 17, 2010 -------- every page. Cityrrown 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 seoaratelv 24 Well more than 150' from SAS \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 22 . . . . . . . . .. . . : . Cleanout 5 utility 28 70 Poles Di•i:v:ewaj� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Long Pond Road Property Address John Finn Owner Owner's Name information is required for Marstons Mills MA 02648 September 17, 2010 every page. CityRbwn 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: 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 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: Pond at rear of property is considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Long Pond Road Property Address John Finn Owner Owner's Name information is Marstons Mills MA 02648 September 17, 2010 required for p every page. Citylrown 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF.ENVIRONMENTAL PROTECTION t eW TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 254 Long Pond Road G� O U3 Marstons Mills MA 02648 Owner's Name: Maureen McPhee Owner's Address: Same Date of Inspection: March 13,2007 Job#07-44 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X_ Passes Conditionally Passes a . Needs Further Evaluatio by the Local Approving Authority t `` Fails Inspector's Signature: . + G-.— F' Date: 3/13/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board o`f Health orY" . DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of I0,000 .- 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 pproving w authority. Notes and Comments: Tank is not in need of pumping at this time,leaching pit has 8-9"of effective leaching. ****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. ` Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 254 Long Pond Road,Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 254 Long Pond Road, Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 254 Long Pond Road,Marstons Mills .Owner: Maureen McPhee Date of Inspection: March 13,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.1 a _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 11 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. Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 254 Long Pond Road,Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up'? _X_ _ Was the site inspected for signs of break out _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 254 Long Pond Road, Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents; 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): N/A well water Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped 7/03 Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 3/18/87 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 254 Long Pond Road, Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees are_intact and clear,liquid level at bottom of outlet invert Tank is not in need of numaint=_at this time. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): • Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 254 Long Pond Road, Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): No solids or high stains. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 254 Long Pond Road,Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number:One 6x6 pit. _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.): Liquid level in leaching pit is 8-9" below inlet pipe with no staining above current level CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): • Page 10 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 254 Long Pond Road, Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 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. 24 Well more than #254 - - 150'from SAS • 22 72 Ar"Cleanout 5 utility 28 Poles 70 28 , 4 a• Driveway Pagel] of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 254 Long Pond Road, Marstons Mills Owner: Maureen McPhee Date of Inspection: March 13,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record- If checked,date of design plan reviewed: _X_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: Pond at rear of property is considerably lower than bottom of leaching pit. AsBuilt Page 1 of 1 TO OF B S BLE LOCATION SEWAGE# VILLAGE AS SSOR'S MAP&PARCEL O-V? O 0,31 *#ST t1`I RS NAME& SEPTICTANK.CAPACITY D6 1 LEACHING FACILITY:(type) 7 (size) NO.OF BEDROOMS, OWNER PERMIT DATE: CQMPH W@E DATE: �3 7 J3 0 Separation Distance Between the: 7�k— v d� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist. within 300 feet of leaching facility) Feet FURNISHED BY I �1I more than 0'from SAS ' :h•:<: 22 .. �leanout 5 ull Poles 70 i I ,r http:Hissgl2/intranet/propdata/prebuilt.aspx?mappar=029003&seq=1 6/27/2014 TOWN OF9 BARNSTABLE LOCATION SEWAGE # 87 �3 VIi,'�.AGE ASSESSOR'S MAP Cz LOT 02,0T INSTALLER'S NAME Cz PHONE NO ��/ SEPTIC TANK CAPACITY /aO LEACHING FACILITY:(type)a � (size) 60 0 NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER * U-0,/ - '� � 2 �- DATE PERMIT ISSUED:. f DATE .:COUPLIANCE ISSUED: 3 r ? -� 9..-7 VARIANCE GRANTED: Yes No 1/ l oe r 41, - ASSESSORS PMIAP No-9.12=1va. Fimic....Qlo............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF...........JU&,vi4el) -..................................... Appfiration for Bi-qVatial Worka (funfitrurtion P.rrmit Application is hereby made for a Permit to Construct or Repair X) an Individual Sewage Disposal System at: ........................... ....*....... .....d&.................................... cation- dress or Lot No. t,.............................. ................................................... "7—* ............................ r I . Address . .............. Installer Address Type of Building Size Lot............................Sq. feet Dwelling AZ-*No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) PL4 Other—Type of Building .................. No. of persons__.:��..................... Showers Cafeteria ( ) 04 Other fixtures ................................................................................................... ................................................... Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. 1:4 Septic Tank—Liquid capacity, 402gallons Length________________ Width.._.__._____.___ Diameter---------------- Depth._._______.__... Disposal Trench—No_ ____________________ Width______._I.......... Total Length______._____.._.____ Total leaching area....................sq. ft. Seepage Pit No-_JZ. -------- Diameter------------Y.... Depth below inlet____________________ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date____________-_______________._________.. Test Pit No. I________________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_._____..._________._._. ::................................................ 0 Description of Soi1....... .................................................................................11�/ 1 Z-34--_1---4---------- ---------------",**-,*,,------------1*----------- .................................................. U ......................................................................................................................................................................................................... W It: .............................................................................................................. ... U Nature of Repairs or It ation,�r—Answer; a P.H.e Z . . ....... ...40. . ........................... ................................................................... Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'_',4- 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 bb/yhe board o a.1th. Ctoo,Signed---__ _---------r---- -------------------------------------- 2..... ............ Date ApplicationApproved By................................................................................................. ....................................... Date Application Disapproved for the following reasons:............................................................................................................. ......................................................................................................................................................................................................... Date Permit No----4517M... ........................ IssuedL........:3........................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............ —-------------------------------- Appliration for Disposal Works Toustrurtiolf Permit Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal System at: , s �� 7 . ation' . . s ........................................«or Lot No. .1 ......= -� ... - - --------- -- ...-._----- / n Address '..... Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling N o. of Bedrooms.......................... .Expansion Attic ( ) Garbage Grinder ( ) p`4 Other—Type of Building ......2................. No. of persons.•_ ........._.......... Showers ( ) — Cafeteria ( ) Q, g Other fixtures g P P P .....---------------------—-----------------------------•••----------------- d gallons per person per day. Total daily flow_.._._.............__......_..._......._....gallons. W Design Flow............................................� 9 Septic Tank—Liquid capacity.//2__.6jallons Length................ Width................ Diameter__._--__•____.•- Depth................ Disposal Trench—No.f------------------- Width.................. Total Length.................... Total leaching area.._s..._.......____sq. ft. Seepage Pit No---J.)........... Diameter............. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1______________-minutes per inch Depth of Test Pit.................... Depth to ground water..................... (Z Test Pit No. 2................minutes per inch Depth of Test Pit.............._..... Depth to ground water•.__-__---_-•__---_-_-_- 04 ............... D Description of Soil......... x x ------------------------------------------------------------ ••---•---------•-•- U nature of Repairs or lte tions Answer when applicab .. "__________ I? ............._.. ..•.._.._._... liUU ................................................../ /> /? Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T i_i 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 he board o 1 lth. Signed. �-------- ------------ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:................................................................................................................ ••-------•--••-•---•-•-------•-•...............••••--------------------•-•-•-•••-----------•-•.•-•••-•--••-----------------•---••-•------•-•-•-------•-----------------•--•-----••---••---••-----•----- Date Permit No..... -1— ] W-- ........................ Issued.........3- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��!Lv''L..........oF........... Kl . Tnrtifirttte of f��am�littnre THIS IS TO CERTI That the Individual Sewage Disposal System constructed ( ) or Repaired (}� bv-------- --•--r •-:_--...g,� -------------------•------•--------------•----------•---•--•-----•-•-•--------•--•-----------------------------....--------.....------------. ``r _�{}� �Jed Installer at._•_... .�d.__`'r-___-_'� T.... <r '�.d_1.-----------v J. .............................. h,s been installed in accordance with the provisions of Ti T i E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......3.~..�.�.'._j 7.............................................. Inspector..... --- .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ]l/ .... OF......... 4 G ,,..., No. .......__�... FEE... ............. Bisposal Workii onstrnrtuan Permit Permission is hereby granted........� -......-•-F - .,�..---....-•--•--•-•--------•••-•-••---------•-----•....................•••......••---«.... to Construct ( ) or Repair ( an IndivLL'dy�1 Sewage Disposal System. at No....... -1-----1-ne-`-" '� rr Q �jLpx---•--••---•-- -- Street y as shown on the application for Disposal Works Construction Permit No 2 2'iy,�_.... Dated.... ^__ .7.__...... ----- ----------- - .. -----•-•--_.._. Board of Health DATE. � FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Jun 28 ]u'1 J7 7: 4UVM F'HIKIL.K U1.U1111tLL vuoTcaaoio r Ilillge 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Piijaiperty Address: 254 Long Pond Road, Marstons•Mills Cllvier. Maureen McPhee ID!116 of Inspection: March 13,2007 SOkTCH OF SEWAGE DISPOSAL SYSTEM Pii lt%4de a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or blillchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. .1 •i. ?c tea' f<. kr%�?::'i}`" •.2,s;f',.^..i:•r:. ' �4k�:,�.v.:^l=fc3,l��' 204 S��• .S>i:��:,"'. #.;;•::�:;s..-+ f.�w. Well more than I50'from AS . �;c>':S:t s. 2L•»a:? „�:}:' i3r Sti•N•`.�:.:^�':^i;"+:��. G �Cleanout Ufli5 28 Poles 70 go- o . ---,�.�.:. - :. _.: _ _ >. y ,n: _ u _ - .,n..:.Y-.' -, -Ate-_."';. — .i _.. - -- .. t - ,_11..* .+. -. - 'ri: ,-:a sue.- .:.i.. - G . -:r _. . - - .. :,.w . .. - .. •4 ..4. . a+ b y9 1 r I , - s ! LO 0I F 4 d`fc x F 4 , ,} 1 h t;." r r..x . .. . �. 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