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HomeMy WebLinkAbout0191 LOVELL'S LANE - Health 191 ll's Lane, Mi—rstons Mills 1 I l I Commonwealth of Massachusetts 0: 'e' - �� Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name / information is Marstons Mills ✓ MA 02648 09/10/2020 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:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road VAQ Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �.._._...._ _._._. . 2�'f :7 09/10/2020 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 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 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: This 4 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a leaching pit with stone. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information i e required for every Marstons Mills MA 02648 09/10/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ b-oken 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 obstructedpipe(s). The Y 4 P p 9 Y 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 11 Title 5 Official Inspection Form iia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane. Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, 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: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ Z 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 lit Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Citylrown 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 Nc ® ❑ 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? ❑ ®i Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form rti1e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... 191 Lovell's Lane V� Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Description: The leaching was evaluated and passes for the 4 bedrooms I found in the home. Number of current residents: 2 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 Seasonaluse? q ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gpd))� Detail: In 2019-64,000 gallons were used and in 2018-77,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i ........... 191 Lovell s Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System ffiformation (cont.) 2. Commercial.11ndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below Grade: 60"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is Marstons Mills MA 02648 09/10/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 52"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Citylrown 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 is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 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(ncte if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc-rev.7726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth o monwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane�., a e Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for everyMarstons Mills MA 02648 09/10/2020 page. CitylTown 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: One ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 f Commonwealth of Massachusetts �� ;� Title 5 Official Inspection Form '�_ F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t; 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth.of Massachusetts Title 5 Official Inspection Form: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Cityrrown 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 ` L a 1 5 Love-it's L#,v.%t Al A2- 6 As:sst =33' t5insp.doc•rev.7126=18 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Lovell's Lane Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus feet 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: I augered a hole at a lower elevation and shot it with a transit. 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Lovell's Lane V� Property Address Thomas Plummer and Susan Taylor Owner Owner's Name information is required for every Marstons Mills MA 02648 09/10/2020 page. City/Town 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. Inspect on Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure-.riteria) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 G COMMONWEALTH OF MASS ACHUSETTS EXECUTIVE OFFICE OF EN-VIROINTIMENTAL_-'kFF,'jRS ' d DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: / �/ 6-- (f �S 44 H Owner's Name: Owner's Address: t.' C Date of Inspection: 12 Name of Inspector: (please print) �/�-�� n �S�// Company Name: ir3 Mailing Address: Telephone Number p Y�L Cl CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the below is true,accurate and complete as of the time o information reported f 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 S 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4� Date:-- The system inspector shall submit a copy of this inspection report to the A ro DEP)within 30 days of completing this inspection If the system is a shared Authority(Board of Health or gpd or greater, the inspector and the system owner shall submit the report to the am or has a design Qow or 10'(l�? priate DEP.The original should be sent to the system owner and copies sent to the buyerrappl2 a�regional office e ofthe authority. Notes and Comments ****This report only describes'conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in conditions of use. the future under the same or different Title 5 Inspection Form 6/15/2000 Page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY-iSSESSI IENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERT IFICATION(continued) Property Address: 1 91 A� f GAS o✓1� K L LS/ Owner Date of Inspection: �J,6 Inspection Summary: Check A,B,C,D or E 1 ALWAYS complete all of Section D A. Sys Passes: I have not found any information which indicates that any of the failure criteria described in 310 C R 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: VBSy�tem Conditionally Passes: e or more system components as described in the-Condit ional tzonal 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. 1 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 IND explain: Tit.n G incnnrtinn t,nrrn 2 - - Page 3 of 11 OFFICI_AL INSPECTION FORM-NOT FOR VOLUTN7-ARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM -INSPECTION FOR-AI PART A CERTIFICATION(continued) Property Address: 9/ Z-0" Owner: a P— Date of Inspection: 3 C7,6 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 15303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines.that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility, and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm provided that no other failure criteria are triggered A copy of the analysis must be attached to this form: 3. Other: T rio G incnontinn �nrm '<17;/7nno 3 ' Page 4 of 11 OFFICIAL INSPECTION FORIM—NOT FOR VOLUNTARY ASSESSME-INTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 191 Z_O ve l& Z-1 C, �/f K :ll 0-6 v� Owner: / S11 ct Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No _ wl Rackup 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 /logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or . sspool quid depth-in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /bf times-pumped _ V y portion of the SAS, cesspool or privy is below high ground water elevation_ �y portion--of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface Lw ater supply. _ any portion of a cesspool or privy is within a Zone 1 of a public welL _ y portion of a cesspool or privy is within 50 feet of a private water supply well, Any portion of a cesspool or privy is.less than 100 feet_but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] AV (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 C.MR 15.303,therefore the system fails.The system owner should coirtact 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) ys the system is within 400 feet of a surface drinldng 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—IW P A)or a==ed 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---ith 10 C VIR 15.304. The system owner should contact the appropriate regional office of the Department. Tit10 incr�ontinn z n�m!./1 C/7/1!1!1 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLLTWARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / CHECKLIST Property Address: 191 L ode//(/S Owner:AC G yLZ-- Date of Inspection: IJ-4 Check if the following have been done. You must indicate"yes"or"no"as'to each of the following: Yes No Pur=ing information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks . 1' Has the system received normal flows in the previous two week period? � ave 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? Tf the were not available note as N!A P Y C Y ) _ Was the facility or dwellinginspected for sips of sewage back ? �P i� g up Was the site inspected for signs of break out? J Were all system components, excluding the SAS located on 't ? Y � g site _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baf or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _7�_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no: Existing information.For example,a plan at the Board of Health. Determined in the field if an of the failure criteria related to Part is at issue ( Y C assue approximation or distance is unacceptable) [310 CiV1R 15.302(3)(b)) Title II Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLU!NT_ARY ASSESSI ITS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 91 GOvei l-r Owner: Date of Inspection: /3 OW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no): / O Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):AV Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no Last date of occupancy: COMMERCLAIM DUSTRIAL Type of establishment: Design flow(based on 310 CTMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL LNFORMATION Pumping Records Source of information: O A4✓' c� �c/S 6 tvie'- ' Was system pumped as part of the inspection(yes or no): !!�D If yes, volume pumped: gallons--How was:quantity pumped determined? .;Reason for p ing: TYP OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1992 .- /?o/Y )1- .1932 , �0 Were sewage odors detected when arriving at the site(yes or no); Ti-10 G In crurtinr� An rrn �./l.G/7(1(1(� 6 - - - Page 7 of I 1 OFFICIAL INSPECTION FORII�I—NOT FOR VOLUNTARY ASSESSI U•NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) / Property Address: 7 / La-e I J Z_ C:r.J N --7k//j (4,/JO Owner: A C ei Date of Inspection: 11f 0 6 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _ PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: 1' ocate on site plan) —( P ) Depth below grade: 2 � / Material of construction: concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth-- Distance from top of sludge to bottom of outlet tee or bale: 0( 7 - Scum thickness: / Distance from top of scum to top of outlet tee of baffle: k Distance from bottom of scum to bottomAf Oputlet tee or be: How were dimensions determined: if- t 4 vl G 2 Comments(on pumping recommendations,inlet and outlet or baffle condition,structural integritT liquid levels Vas lated to outlet invert,evide ce of leakage,etc): �` � , 1.1 G.7 cv, ee.s / o� if1 GREASE TRAP: (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: _omments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,-liquid levels as related to outlet invert,evidence of leakage,etc.): Tith 1^eno�tinn }=nrm 41,S/7n(In 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSVIE-N7S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: P � l pvalf 1-4-1 Owner: '+q Date of Inspection: 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX- if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: G-- Comments(note if box iz level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage int t of box, et¢.): / 5 7 L-eye K �/t 0 Sc PUMP CHAMBER: locate on site plan) ( P ) Pumps in working order(yes or no): Alarms m working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Ti+Ta Tncnni+inn Rnrrn 4/1G/"Inn) 8 Page 9ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS'YIF ITS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM/ INFORMATION(continued) Property Address: Jon 15r Owner: Ac Date of Inspection: za SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: leaching pits,number: X leaching chambers,number: J 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.): Z "7` f' s /Ct-< 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 or no): Comments(note condition of soil,signs ofhydraulic failure,Ievel ofponding,condition ofvagetation.etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil,signs of hydraulic failure,level ofponding,condition ofvegeLation.etc.): T tla fnenortinn �nrm/,l1�17I1I1(1 9 Page 10 of 11 _ OFFICIAL INSPECTION FORM_ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM L TFORVIATION(continued) Property Address: l /f� I—ove l&- L-,I/ Owner: �C Gi Date of Inspection: 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 a budding: 0? �A2 -- � Ie a , 411:i,ynnn 10 Page 11 of I 1 - 'OFFICIAL IiNSPECTION FORM—NOT FORVOLUTNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- , Or �� A 0 Owner: f "t G Date of Inspection i.1 ' SITE EXkml Ln + 7 Slope q �. a- Surface water Check cellar ` �r Shallow wells Estimated depth to ground water 39��feet LP 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: served site(abutting property/observation hole cvijhinQ rat of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ow y established the high,_0r round water elevation: ! o ' © t�S 410 l J -? [ o (ja ,0 y 000a f Tc v-vt b 01 Title G Fnenanrinn F+nrm�./l il7nM k Lovttl s L�,v.e a r 1 ` 33 of L TOWN OF BARNSTABLE %' LOCATION d ve l l_9 ►�p SEWAGE # S - .03 VILLAGE-Mn,cSi-O iM. Iv`A(s _ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �er tb o k�1 .nhsh uc �bv� lb SEPTIC TANK CAPACITY t P [ ti ' `` LEACHING FACILITY: (type) �- _ _ ���' (size) N�'D.OF BEDROOMS ,A OR OWNER n C 0 h tC'.�G'�'i p Y1 PERMTTDATE y 3 - 2 - g S COMPLIANCE DATE: Synaration Distance Between the: k4imum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist t; on site`or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) i Furnished by - 1 TOWN OF BARNSTABLE I LOCATION L 1- in, �-ve k _9 L _ y-%Q - SEWAGE # /S- 3 70 VILLAGEM( r-tQ"4- t�A A l-5 ASSESSO�R`'S MAP & LOT 678-024 I INSTALLER'S NAME&PHONE NO.RmC t'®��• '�'i lt�i�S{` Ca1�1c�►� �)Z �I�6 SEPTIC TANK CAPACITY 1600 �4 C. LEACHING FACILITY: (type) L_ CAL h "R (size) AD aeJ, NO.OF BEDROOMS n OR OWNER O��� 0 fvbtro r-,�i a n BU�,1f,�R 1"1 L PERMTTDATE: U 3 — Z _ �� .COMPLIANCE DATE: / — t2 — 9 7 SepD�aration Distance Between the: um Adjusted Groundwater Table and Bottom of Leaching Facility Feet IM?' Private Water Supply Well and Leaching Facility (If any wells exist 7 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 Love-it's Lovq Al A2 - L4 AS 55 U23 g14c) assFes01,(;r0AP No: Q24 —7�0 7 FEB9� 7� : PARCEL l�o: 2(o a NO..... -•-•_L7.15_v ..........................._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L/ TOWN OF BARNSTABLE Appliration for Bi!ipwml Work,i Tomitrnrtinn Famit Application is hereby made for a Permit to iistruct ( ) or Repair ( ) an Individual Sewage Disposal System a�} / 1 �, --•- C�Looctttioyn-Add' J 1 Corr L( No. -----------------•------ .--.�JrcW4__y------�.d!?��.--'�-,-`-4-*------------ 1.ilkX Y..��..��.2. 4�".�� Oo ner Address W Installer Address 04 `Sq. feet d Type of Building Size Lot..__�.... ...2.-........... Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic (LL Garbage Grinder (4b aOther—Type of Building _._---_-_11.I._A.._._.. No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- -----------------•----•-'-----------'-'••--•---.............. W Design Flow..............?'~�..._.._.._..___._._gallotls per person per day. Total da.ily flow--- - ?3 .....__.__._.....gao..n Lp . _ R: Septic Tank—Liquid ca acitv__1P a]lons Length Width.5 � Diameter.u �_____. Depth..:_! :'®.l...gy. m r n Disposal Trench--:�'o. ..__ rA_.... Width.............. ...�Total Length ---------4......... Total leach: area--------------,,...sq. ft. �!►,Seepage Pit No-------- ....... Diameter---�c% ..c�_f D'ept�er-5w inlet..._--"✓-•.......... Total leaching area..3037-..sq. ft. Other Distribution box ( ) Dosing to ( ) 4�kk Percolation Test Results Performed by.---_--rX ( ...__. ._..._ ........ Date.... _`.3." - ........ ,..1 Test Pit No. I-___--_-2-...-minutes per inch Depth of Test Pit._.._ �...._...... Depth to ground water..._. olaE'----.--. rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__ !.%JCQM _.k-vVce� a9... ... ----� -------- --Z.©-t............T.............................••-•......._-- O Description of Soil..._.?.a-.-Z ®__....�... !Q-- 4?- So `t................. U ----------------------------- 25!...-.-......!s-ICt.. _..---.....-•-----•-•--....---•-------•. .... ....................................................................... W ........................................................................................................................................................................_............................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... --•------------------'------...-------'------------'-------...---------••--•---••---...........--•••----'•--•-----------------•---------.........-----------------...--•---•'-'--------••-•-•'-......... i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isr-Lsued the board of health. Signed ............... 'J3 ?A Dare ....................... Application Approved By ............ ...�...................................................,r.... .. ............................. ..-----• ..77� ...-�"f`. Dace Application Disapproved for the following reasons: ..... ............................. .. .......................................................................................... ................................................................................... ........................... ...... ................................................ .. ............... .................................. Permit No. . '9 r �� _Y_5- Date .................................................. ... Issued .................................................................... Date --.—_.—._—._._._-----.__________________________________________________. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTHDESIGNING ENGINEER MUST SUPERVISE INSTALLATION AND CERTIFY IN WRITING TOWN OF BARNSTABL.EsNl'�TF-�A LAWS PYST&I_I_ED IN STRICT C er#tfirate of C�om lt`�x THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............. ..... ....... .............................------.----.....-----------------------.....---------.-----............-........ --. ............----------..........-------------------------------------- at ....._...�4........ �UG/iS'........ -- .................................................................................----- C.� 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. ..5 :- ...-..---.--- dated --- .,1 ._-f.57.._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... ......................................_....._..........._............................. Inspector ._...------------.......---...........--------------._-----------------.--------- -------- ------------------------------------------------------------ --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH DESIGNING ENGINEER MUST SUPERVISE INSTALLATION AND CERTIFY IN WRITI G QQ TOWN OF BARNSTABLBIE SYSTEM WAS INSTALLEgV�S, T No......l... '. 02 ACCORDANCE TO PL�E........................ Dispotial Gorki Tono#r inn "lermit Permissionis hereby granted-------------- --_-_-------------•------•-------------------------------------•---•-------------------•-----------------••---•----•-•-•-•- to Construct (> or Repair ( ) an Individual Sewage Disposal S stem �. at No......L& ....S....-•-�Lt�/ ig....L��•Pr..... . ----- �-------------------------------- Street as shown on the application for Disposal Works Construction Permit No.-q-----"_--_---- Dated.....3....... .. _..... .... Board of Health DATE................................................................................ - FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS 1�v- .� .: ..mow. ...,�_�,,..,.�-;,...z�..�...-�.� r,,.�..� ✓'•7.,,:,;Ar '--..,.w{f-..•..i.,•.� ,�a � _ �V,,. ,v. �. � li.:..i- ..v v .+ -�. No.... Fas .............._. ......�.... THE COMMONWEALTH OF MIASSACHUSETTS j BOARD OF HEALTH TOWN OF BARNSTABLE t/ G , Appliratiun for Di ipwial Wnrbi Tvastrnrtion rrmit Application is hereby made for a Permit to Qonstruct ( ) or Repair ( ) an Individual Sewage Disposal System at- / 1 d, fll ,�� --- _• -- Location-Addrve� ��y�, or Lot No. _..... 1451:�....X �°"'s .tea - Owner Address •---.....-•---•------------••---....•----...-•-•-----•-----------••---•-•----•---••---------•----- ----------------------•---••-•---•••..........•-----------•-•----••--••-•--•-------•••••......••-• 'I Installer Address Q Type of Building Size Lot____� i ZOC---.'Sq. feet Dwelling— No. of Bedrooms__________ -----------------------------___Expansion Attic (LA,) Garbage Grinder (4) aOther—Type of Building ----------v.LA_..----- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ..................... '------------------••-•-......--------••-•......-•-•--•---•-•-- ••---•---•--•••-•---••-•------•---•-•--•---------•-•----•---• W Design Flow.............. ..................--gallons per person per day. Total daily flow...------------;3-3�......._.........gallons. Septic Tank—Liquid capacity_ aPI;gallons Length-__- Width-S."�I___ Diameter.0_�_ __.... Depth.... t Disposal Trench—No. __.. ...... Width................. Total Length..........1......... Total leaching area..._.........�..sq. ft. Seepage Pit No--------�.......... Diameter._k-�_..,., 3.)leptl below inlet....r.: .......... Total leaching area.�;O3._r...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ff11 '~ Percolation Test Results Performed by........ .,.,-p, ? �:4.�._..`_ _��.`.�u.._...... Date....�.`.3.-1._2......... Test Pit No. I-------- -_--minutes per inch Depth of Test Pit._.__1__!..__....... Depth to ground water... .?nrfn....... LL, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_...._P.! W q! tlr. R+ ...................-••••••.... -- - IAN WA Description of Soil---- = z'`� ----- ------ -`-;"-'n_. , --- 1_�.. ....9.rh •turn.!a V .....................................�.NYC....4�.....S�Q..... 1..^..............__................._._......._........__.•�...............................................1..._.--.. W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ...................... ----•-...............-----•-•-•-----••-•-••---•----••-•--••..................-•-.....•--•••---------•-•------•-•---•--•-••--.._...-•-•-..............------.............•....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been;sued .y the board of health. Signed ............ . .....:� ...................... � i � � � - -- Dare A lication A roved B / ' K- ...�.. ��....-.C�r PP pP y ... .......................... r.......................................... Dace Application Disapproved for the following reasons: ......................................................................................•................................................. ....... ................................................................ ............................ .................. .............................................. ..... .. ........................................ / 20 � PermitNo. ......................................... ...............- Issued ............. ......................................... Dace THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH - TOWN OF BARNSTABLE C�Er#tfirate of Tarapttttne THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ..... ........ . ...... ............... - .............. .....__...... ...... -... ........ ......... -_.... ............ .-- ....... .................................................. / - z m,�aue� — at _... .. .'�........Jr..._ -�UC��S. ----------%�4 u/- .A ............ . ... .... -- ................................ 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. _,J _=-...74�2............... dated ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .._.... _......_...._.__..._................._..-........-----------...-.------_.... Inspector ............-------------------------...-..---------......------_------------------------ ------------------,------------- ----_---_.- ---.--_- ----- - - --- --, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S r TOWN OF BARNSTABLE No....... -..... 0� FEE.......ADD............•••. �i �a ttl nr� Tonotrurtaan "unfit -+ Permission is hereby granted--------------------------- to Construct ( or Repair ( ) an Individual Sewage Disposal System atNo......L-o-4.....-�--------LA-x._I : .... ,r!f......> -------------------•---------------- ------...-------••---............. Street I' as shown on the application for Disposal Works Construction Permit No......................... Dated...... _'..�...-.. ....................................................................................................... Board of Health DATE------------------------•--------------..-.-•---------------.------------..:::.: - FORM 36508 HOBBS R WARREN.INC..PUBLISHERS ri APPROX. LIMITS OF 444 NEW ENGLAND T&T 1929 BOOK 4691194 \ , t _ . LOT 4 OF rf , ,r F \\aa PAUL a \ U-POLE dkUL O36017.5 � � � f'•' / VC1, I�o.32488 c CISTER��J� �Q GUY t taro B3 U� v.aas Oti, , d LOT 3 ��/, ` ' \ FLOOD ZONE "C" - �g �' co �\ ASSESSORS LO T. 24— 7 04N0 3 ` \ � �= \ BENCHMARK, PLAN REF, 486/49 m. �� 5 \ 6 \ -RES. ZONE »VB_A, TOP OF SEWER REAR SETBACK 20' 62 ASSUMED FRONT SETBACK 10' `�-� I ��. \ �� �- \ ELEV, = 50. 00 SIDE SETBACK 10' MIN, 30' TOTAL CESs POOL 64 II ✓` ,\ fl 1V PROJECT LOCATION LOT -5 o�oo L T 10, 0 \ \ \ LO VELL'S LANE - � -�s � LOT 6 - o��� \ BARNSTABLE, MA, RESERVE AREA \ S APPLICANT Mc SHANE CONSTRUCTION LEACHING 31 \ LO VELL S! LANE PIT 10��22 BARNSTABLE, MA 641 - YANKEE SURVEY. CONSULTANTS �= + UNIT 5, 40B INDUSTRY ROAD R 0. BOX 265 LOT. MARSTONS- MILLS, MA. 02648 LOT. 8 TEL: 4�.8 0055 I'A�i. 42 0-5553 , NO TES. . - , ;: 1 » 30, THE GENERAL CONTRACTOR IS REQUIRED TO SCALE' — DATE 01/25%95 HAVE THE SE WERA GE..S YS TEM STAKED BY THE = - SURVEYOR PRIOR TO PLACEMENT. RV.'E 12104197 REV. x " , = } �.� 50626B- 2 B< NO 1 O _., r _. r,. .. �. .. ... ,...4-:. .» r. ..._.. ,...,,«. aa. .,.. _,,_ ,._e ,r - _ ._ t.,tv.-,-Y i+..._M..--.......-,.. .�,i- -..a.. .. ,n a -.. _..a_• >vu ..t.:::._ _y....�...,•,�. .-:n: .......... :.s-..._:..:t:.. _'C vt.... ..f_, vu of v s - -. . .. w_:...-... _..,..-...-._;^.,._ -_.... ........... .. _.. .. .:....,.. <.:' ..:-..-. ._' .. .,. ..,.-_ .»..:•...: -., .. ..•V_'.Ie.:Y ..c.-v' ..._`.H�v_.. v.....�.: ..._ ..,..sf.....as ,..-,.-_ ».,ems...,,.. -x._...c.:-T.d:.._`., ..-2e...,,_..._.._ 1.:.,,.... _ .._..�x„_ ... ..-,..-._.x ✓ ._...Y - __— __ , _._ . - — — -. Y _ _ TOP OF FOUNDATION : 20' MIN." i CONCRETE COVERS 2"LA YER OF 4 52.3f- PROPOSED . - GROUND EL.__ 52.5 PRO OSED 2 �7 CONCRETE CO VETS WAS ED STONE / / / � OR SCHEDULE40 '24t " � / / 63.0f P. V.C. PIPE S=0.02, D=14.5' 4" SCHEDULE 40 P. V"C.D MN FLOW LINE S=O. 0 , •D=4.4PE — MIN. BOX i lo" S 0. 02 D=14.5' MIN. 19 d e" S 8 e 8 / LEACHING INVERT CRUSHED o S q IT OR STONE o %o*g* % W - ° EQUIVALENT INVERT EL.=_49.55 , q EL_.=_ 49.29 c °° 49.80 ° 5 [r < 9/4' TO 1-1/2" — 1000 GALLON °° w 0 WASHED STONE EL.=_49.46 EL.=_49.0 _ ° ° _ SEPTIC TANK ° W c _ 44. 0 H-20 LOADING I LEACH PIT 3' - 6' 3' PROFILE OF 12'DIAM - SEWAGE DISPOSAL SYSTEM - INVERT ' NOT TO SCALE BOTTOM OF TEST HOLE OR VSGS PROBABLE WATER TABLE EL= 52.0 50.19 i if — ALL ELEVATIONS ARE ASSIGNED J. LANDERS—CA ULEY,PE WITNESSED BY: J. DUNNING e HEAL TH OFFICER TOWN OF BARNSTALE SOIL LOG ! GENERAL NO TES 2 PERCOLATION RATE _ __ MIN./ INCH — P NO. 7940 1. THIS PLAN IS FOR INSTALLATION OF NEW SEWERAGE DISPOSAL SYSTEM" DATE _09-3-92 ** LOT 7 PERCOLATION TEST WAS TEN (10) FEET VERTICALLY! OWER" 2. PLAN REFERENCE BOOK 486 PAGE 4 9. t — NO WATER WAS ENCOUNTERED DURING THAT TEST. 3. THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM TEST HOLE 2 t TEST HOLE 1 AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES. DESIGN DA TA: EL._ 63. 0 EL. _ 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO- D-E-P" — TITLE .5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. LOAM aand -777, NUMBER OF BEDROOMS THREE 5. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 2' SUBSOIL ' NONE 12" OF FINISHED GRADE. GARBAGE DISPOSAL i 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE, . SAME, UNLESS NOTED BY FINAL CONTOURS. TOTAL ESTIMATED FLOW 330 GPD 7. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE + ( 110 __GAL./BR"/DAY x -3__ BR.) OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER MEDIUM it OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING_ COARSE SAND SEPTIC TANK CAPACITY _I000__ f SHALL BE USED UNDER OR WITHIN. 10' OF DRIVES OR PARKING_ UNLESS NOTED. 11 LEACHING AREA REQUIREMENTS — 0. . ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN PLACE. :d SIDEWALL AREA 189 GAL,/S,F. 189x2 5=468 9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BO TTOM AREA 113 _ GAL,/S/F 113x1. 0= 113 , DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO ;+ LEACHING CAPACITY (BOTTOM & SIDEWALL) 581 GAL. _ OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. WATER ENCOUNTERED 10. THE EXCA VA TOR CONTRACTOR SHALL VERIFY THE LOCA TION OF ALL-- UNDERGROUND UTILITIES PRIOR TO ANY EXCA UA''ION. THE WATERGATE WAS NOT ,FOUND THE GENERAL RESERVE LEACHING. CAPACITY 581—_ ,r CONTRACTOR SHALL VI RIFY LOCATION WITH WATER DEPARTMENT.. GAL O SHEET. 2:. OF 2 _ NO.`JOB '?R' .A• •"S, N,<.' .e _ ..- ._ ,_. .. .. ._ --;- -. .. _ ...U+t. ,. .. -t_ .�,. •.. .-� 4. "�- 0. "'�' ".3 .4•�' 'i .,....: Z....., _.-.. _ ., .. _ 9.... ..../ -.'-x•. r ..,s. .. ,7. ,.?^... ._. � e' . .- .. h.. Y- 40 p- '7® ° APPROX. LIMITS OF NEW ENGLAND T&T r 1929 BOOK 4691194 LOT 4 \ \ \ \ U--POLE \ �/,¢360/7.5 / \y� ourKRE /i LOT 3 gI /,� FLOOD ZONE "C" \ � o �� ASSESSORS LOT 24- 7 G�%°A0 \ \ BENCHMARK PLAN REF.- 486/49 V6 RES. ZONE "VB-A " TOP OF SEWER REAR SETBACK 20' T 6� � ,`''rn_ \ ASSUMED FRONT SETBACK. 10' CD ELEV. = 50, 00 SIDE SETBACK 10' MIN., 30' TOTAL CESS POOL _ 64 'ooV�� \ N° \ PROJECT LOCATION LOT 5 o L O, o fs LO VELL'S LANE' LOT 6 off, \ BARNSTABLE, MA 0 RESERVE AREA \ APPLICANT Mc SHANE CONSTRUCTION LEACHING gti \ LO VELL'S LANE PIT 0 q BARNSTABLE, MA OF LANDERS CAULEYy ���`jv � C civic o y YANKEE SURVEY CONSULTANTS 101 VAU.A°MLRMiE* UNIT 5, 40B INDUSTRY ROAD �EcISTE" ``� �" y P. 0. BOX 265 LOT 7 ronrAL E�G�� �paNPQ' MARSTONS MILLS, MA. 02648 L T R i �yoSUR� TEL. 478-005' FAX 420-5553 f NO TE'S.- THE GENERAL CONTRACTOR IS REQUIRED TO � � SCALE 1 = 30' DATE. 01/2 I E 5/95 HA VE THE SEWERAGE SYSTEM STAKED BY THE SURVEYOR PRIOR TO PLACEMENT. - �i'® REV 12/04/9 7 RE V JOB NU 50626-H SHEET 1 OF 2 62 8 TOP OF FOUNDATION �~ ' 20' MIN. CONCRETE COVERS 2"LAYER OF 52.3t PROPOSED _ 52 5 PRO OSED 2' 1/e"-1/2" GROUND EL.-_-- CONCRETE COVERS WASHED STONE �� LEVEL 63.02L. OR SCHEDULE 40 P. V.C. PIPE S=0.02 D=14.5' 4" SCHEDULE 40 P. V.C.DIS 12 PIPE — MIN. BOX M N. FLOW LINE S=0.0 D=4. 4' 110- S= 0. 02, D=14.5' / PRECAST MIN. 1 6 ° °° LEACHING INVERT CRUSHED o g OR STONE o °°°°°°°° o W ` ° EQUIVALENT °°°°°°°° INVERT EL.=_49.55 49.29 c EL =_49.80 EL=----- 0. °c ° 5 ° 3/4" TO 1-1/" " 1000 GALLON °° W °° WASHED STONE EL. =_49.46 EL.=-49.0 — ° ° SEPTIC TANK ° W °`. _ 44.0 H-20 LOADING LEACH PIT 3' — 6' 1 3' PROFILE OF 12'DIAM SEWAGE DISPOSAL SYSTEM INVERT NOT SCALE BOTTOM OF TEST HOLE OR VSGS PROBABLE WATER TABLE EL=_ 52.0 50 19 EL.--- ALL ELEVATIONS ARE ASSIGNED J. LANDERS—CA ULEY,PE WITNESSED BY: J DUNNING _ HEAL TH OFFICER TO WN OF BARNSTALE i GENERAL NO TESSOIL LOG 2 P NO. 7940 PERCOLATION RATE MIN./ INCH 1. THIS PLAN IS FOR INSTALLATION OF NEW SEWERAGE DISPOSAL SYSTEM. DATE —09-392 _ ** LOT 7 PERCOLATION TEST WAS TEN (10) FEET VERTICALLY LOWER. 2. PLAN REFERENCE BOOK 486 PAGE 49. NO WATER WAS ENCOUNTERED DURING THAT TEST. 3. THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM TEST HOLE 2 ` TEST HOLE 1 AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES. T�� T�e. EL. = 63. 0 ' DESIGN EL. = 1 �Y ll 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. — TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. LOAM hand NUMBER OF BEDROOMS THREE 5. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 2' SUBSOIL 12" OF FINISHED GRADE. GARBAGE DISPOSAL NONE 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME, UNLESS NOTED BY FINAL CONTOURS. Fg� Uf � TOTAL ESTIMATED FLOW 330 GPD 7ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE � � ( 110 __GAL./BR./DA Y x _3__ BR. OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER MEDIUM to OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING COARSE SAND NO,32M SEPTIC TANK CAPACITY —1000__ SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING. UNLESS NOTED LFACHING AREA REQUIREMENTS 8. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL 11' r�ND SURV��� BE MORTARED IN PLACE. SIDE,WALL AREA 189 _ GAL. /S.F. 189x2 5=468 9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BOTTOM AREA _11_3 GAL./S/F 113x1. 0= 113 DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO LEACHING CAPACITY (BOTTOM & SIDEWALL) 581_GAL. OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. NO WAITER ENCOUNTERED 10. THE EXCA VA TOR�CONTRACTOR SHALL VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES PRIOR TO ANY EXCAVATION THE WATERGATE WAS NOT FOUND, THE GENERAL RESERVE LEACHING CAPACITY 581_— GAL. CONTRACTOR SHALL VERIFY LOCATION WITH WATER DEPARTMENT. SHEET 2 OF 2 JOB NO.: 50626E i