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Home My WebLink About0109 MARQUAND DRIVE - Health 109 Maraquand Drive Marstons Mills A = 077-037.006 I I. IIl Commonwealth of Massachusetts b3� _ DO Title 5 Official Inspection Form I,.. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r °M 109 Marquand Drive Ull Property Address p a Chris Babcock k Owner Owner's Name information is 3� required for every Marstons Mills Ma. 02655 07-03-2018 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Q Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification 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 El Needs Further Evaluation by the Loc Ing uthority 07-03-2018 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 0�wt/o— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655' 07-03-2018 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: This 3 bedroom home has a H-10 1500 gallon septic tank and a H-10 D-Box feeding two leaching trenches. At the time of the inspection there were no visible signs of past hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N FIND (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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Marquand Drive M Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 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 I` ❑ ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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 plus gpd t5ins.doc•rev.6/16 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 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 III Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 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 ,M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No. Building Sewer(locate on site plan): Depth below grade: 15"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: 6"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 Standard H-10 1500 gallon septic Dimensions: tank Sludge depth: 1" t5ins.doc-rev.6/16 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 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 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 36" 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 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 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 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is Marstons Mills Ma. 02655 07-03-2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: two 4 x30 x 2 ❑ 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.): At the time of the inspection there were no visible signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. Cityfrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 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 separately t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ��. TOWN OF BARNSTABLE LOCATION 1199 MAC GLVP y1,jr�� :�r SEWAGE# Q�- VU-LACE J�'/i�� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J Soo LEACHING FACIL TY:(type) 77"1. (size) y X 30'x .1" NO.OF BEDROOMS 1 BUILDER OR OWNER /� RI Shop PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 fat of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Deck 1 q1- �S Q►- 19 a i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 109 Marquand Drive Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 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: augered a hole to ten feet. i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 a Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Marquand Drive M Property Address Chris Babcock Owner Owner's Name information is required for every Marstons Mills Ma. 02655 07-03-2018 page. City[Town 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 109 Marquand Drive Property Address James Grace Owner O er's Name information is required for v'ay*nj nil f Ma. 02655 1/29/2010 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 A. General Information forms the computeto r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ---t ❑ Needs Further Evaluation by the Local Approving Authority ' t �— 1/29/2010 "� r Inspe tor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority.:(Board; of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or----I has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submitthe 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•09/08 Title 5 Official Inspection Form:Subsurface Sewag isposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 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•09108 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 �M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town State Zip Code - Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon septic tank,D-Box and 2 leaching trenches. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2008:138,000 g ( y g (gp ))' 2009:19,000 Detail: 2008:378gpd 2009:52gpd Sump pump? ❑ Yes ® No Last date of occupancy: 1/29/ 10 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 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 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 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: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date Installed (If known)and source of Information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1' Depth below grade: - feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 0 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 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 Lt5in�-109/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids cagyover.No evidence of leakage. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2/4'X30'X2' ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Trenches were dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size . ■ zoom Out I I'I I jIn 11 IC 'RICU �y yyfJ Y _ . tf. r � g d 39' 3 ' 0 2:0 Feet Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER r`^—inhf 9fVK_9fMn T—in of Rornefohln RA All rinhfc rac—, .._fl._.._.__..�_T71 f%P7'7 f%I1'7 A A/'0 /1%AI fN M Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town 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: Bottom of leaching 33' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 109 Marquand Drive Property Address James Grace Owner Owner's Name information is required for Osterville Ma. 02655 1/29/2010 every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 d y' \ Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection / . One venter Street, Boston MA 02108 (617)292-5500 Apo R y0 TRUDY COXE ecretary VS ARGEO PAUL CELLUCCI DAV D B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 109 Marquand Drive, Osterville,MA Name of Owner: Al Bishop Address of Owner: Same Date of Inspection: April 7, 2000 Name of Inspector:(Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville,MA 02655-0049 Map: 77 Telephone Number: (508)862-9400 Parcel: 37-6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluati n y the Local Approving Authority ails Inspector's Signature: Date: April 10, 2000 The System Inspector shall subrn copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1of11 Printed on Recycled Paper r � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 109 Marquand Drive, OsterWle, MA Owner: Al Bishop Date of Inspection: April 7, 2000 INSPECTION SUMMARY: Check A, B, C,or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken.or obstructed pipe(s) or due to a broken,settled'or uneven distribution box..The system.will pass.inspection if(with approval of the Board of Health).. broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): 0 broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 109 Marquand Drive, Osterville, MA Owner: Al Bishop a ; Date of Inspection: April 7, 2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water.supply. . 'The system has a septic tank and soiLabsorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (appro:dmation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 109 Marquand Drive, Osterville, MA Owner: Al Bishop Date of Inspection: April 7, 2000 D. SYSTEM FAILS: You must indicate either"Yes"or"No" as to each of the following: I have determined that one or more of die'following' failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 'h 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 H of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 109 Marquand Drive, Osterville,MA _ Owner: Al Bishop Date of Inspection: April 7, 2000 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ Now of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank'was inspected for conditions of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: - ✓ _ Existing information. For•example,Plan at B.O.H. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)l• ✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 109 Marquand Drive, Osterville, MA Owner: Al Bishop Date of Inspection: April Z 2" FLOW CONDITIONS RESIDENTIAL• Deign flow: 110 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 Total DESIGN flow 354 Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry(separate system)(yes or no): No; If yes, separate inspection required Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): 1999-235,000 eats.:1998-253,0001tats. Sump Pump(yes or no): No Lan date of occupancy: Currently occupied C0MM RCLAL/INDUSTRIAL• Type of establishment: Design flow: eod(Based on 15.203) Basis of design flow 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: 0.1 OTHER: (Describe) _-- Last date of occupancy: GENERAL'INFORMATION PUMPING RECORDS and source of information: Not pumped since installation-per owner. System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other ; i APPROXIMATE AGE of all components,date installed(if known)and source of information: Sept. 3196-per as built card. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Marquand Drive, Osterville,MA Owner: Al Bishop t• t .< . ,z. Date of Inspection: April 7, 2000 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron 40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 10"• _. i, Distance from bottom of scum to bottom of outlet tee or baffle: 10" How dimensions were determined: Measuring stick Comments: _ (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) The tees were Present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene' other(explain) ` Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Marquand Drive, Osterville, 111A , Owner: Al Bishop ;, Date of Inspection: April 7, 2000 TIGHT OR HOLDING TANK: None (Tank musf"be pumped prior to,or 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: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level. There were no signs of solids or leakage and no signs of backup from the infiltrators. PUMP CHAMBER: None (locate on site plan) Pumps in worldng order: (Yes or No) Alarms in worldng order: (Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) A revised 9/2/98 Page 8of11 f - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Marquand Drive, Osterville,MA Owner: Al Bishop Date of Inspection: April 7, 2000 `w SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,if possible;excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: leaching chambers,number. leaching galleries,number: leaching trenches,number,length: 2-4'x 30'x 2' (see design plans) leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The trenches were not dug up. There were no signs of failure in the D-box. CESSPOOLS: None (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(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Marquand Drive, Osterville, MA Owner: Al Bishop Date of Inspection: April 7, 2000 Map. 77 Parcel: 37-6. SKETCH'OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Al - a Aa_ 3°1 , i f revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Marquand Drive, Osterville, MA Owner: Al Bishop Date of Inspection: April 7, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth:Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: ✓ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of Health + - _ Checked FEMA Maps Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) A perc test was done when the system was installed, and no water was observed at 144". Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(MI W 29, Zone C, 3100)was 3.9'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, reltufng to the system, the inspection and/or this report. revised 9/2/98 Page 11of11 f 4 TOWNI OF BARNSTABLE LOCATION tr. SEWAGE # VILLAGE d ASSESSOR'S MAP& LOT Csl'1 3l' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SOrU LEACHING FACILITY: (type) r0_Ae,6 (size) NO. OF BEDROOMS BUILDER OR OWNER 91 S�V PERMTTDATE: COMPLIANCE DATE: f 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 facility) Feet Furnished by deck If Al- 19 ' a Aa- TOWN/OF BARNSTABLE p LOCATION lOf / 01��1,C�i9�" �� SEWAGE # f�' / VILLAGE f_ESSOR'S MAP& LOT 7 -03% INSTALLER'S NAME&PHONE NO. Al felO j SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) (size) ,A�d NO.OF BEDROOMS 3 ��MS // BUII.DEROI�OWNER �G5/0, PERMTTDATE: Z6`Q6 COMPLIANCE DATE: ' Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 40 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of_IpNhing facility) r° �y Feet �I Furnished by �r� � 5 13 . sa y3 ASSWORS MQ M '+ No. • Fee/ !![�_� THE COMMONWEALTH OF MASSAC PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Mizpooal *p$tem Con.5truction Permit Application is hereby made for a Permit to Construct Q( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Ats5cssam YMtp 77. tOunte-/ 37-6 '54o►,y Pbntg Cir- Lv- / v 4• v,"4 �riue� 1^u1�lL 1n&r'5fVn5 1m.'Ik, &Z_&418- (502 r)AZ0--07Q Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 4 c u y �Ct/rcc� r IU ", .� -Z Type of Building: Dwelling No.of Bedrooms 111 Garbage Grinder(410) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 6ar-_c ?,, i i O gallons per day. Calculated daily flow -_R? 8 gallons. Plan Date 1 Z/Q-iS Number of sheets Y7- Date_I z_/6 s�4T Title Si&r. p1G11 E Silo-lic fkpt�in Description of Soil J bu.`.hSnndk 47 n e- i 11 PP �- c1 "- .4" v F r"1 6 Z'411'�' ;- STEPHEN Nature of Repairs or Alterations(Answer when applicable) o.3321i6 ens Date last inspected: w • Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage isposal system in'accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his d e�ltljJ � Signed Date Application Approve y Application Disapproved for the following reasons .-.- Permit No. Date Issued �— `,. \, 4 +.,,, 4" 9�' .e^" ^t M'.,'�- i�'°tiJ—r"'�„,✓r."M"�MKyr�.-�...-..1�.�.,..�_.�..�r.., t ._ 4 .. --., 0 -7 No. •.^► €, ~ .✓ ► r ' Fee P y THE COMMONWEALTH OF MASSACHUSETTS K. -� P B1_I04HEALTH DIVISION - TOWN OF BARNSTABLE, MA S.SACHUSETTS fp Ytcation for MigPo!5a1 *pgtent Conztructton Permitr Application is hereby made for a Permit to Construct(,X or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. � Owner's Name,Address and Tel.No. ht5sc ssors rilnc+ 77j l/2-arcc 37-6 A.w. 3t SiKoP , lc7 Sony Pond C1 -c CQ �u hh4 •+�P �rtvc� Oslcru�Ile �'larslTms IYjl�Ils� D�gfr (sob 07 , 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. L cvr ACC/ a ¢ lt.�frrs.- / s x• %ac. -Z r H�1( i2x.+ca/� Lc6.k'rtJi/lt aZG3L t Type:of Building: D tilling No.of Bedrooms Ikr-ce. Garbage Grinder(4/10) Other Type of Building No. of Persons Slidw-eps,( ) Cafeteria( ) Other Fixtures Design Flow 3 �6ed¢rdcmts n H O gallons per day. Calculated daily flow 33 8" gallons. Plan Date 1 Z/6 /9S Number of sheets Tara Date IL/S Title S,kc. Pla h k Semi c, tic ran .^x Description of Soil TP 01' "A Floc► O-�` 8� ko.-t " " 5*&+,fk.j saed i 47i n e "•- a A",Z ' n " oz Gy Pi .. Nature of Repairs or Alterations(Answer when applicable) 1 kill'IfIR11 0.36216 m Date last inspected: - Agreement: The undersigned agrees to en ure the construction and maintenance of the afore described on-site sewage isp" in accordance.with the provisions o�Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is d ealt Signed Date - i Application Approve y _ Application Disapproved for the following reasons Permit No. �"T� Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance � -a THIS IS TO CERTIF tat the On-site Sewage.Disposal System inst lled(�or re redhe laced( )on by for �&Z i-d, as / �'✓ has been constructed in acc ance/ with the provisions of Title 5 and the for Disposal System Construction Permit No. �+ dated �"',..� "�6 . Use of this system is conditioned on compliance with the provisions s5,4fth below: Illi '. P� `---------------------- ------------------ ----------------------- --__--_____=_—_----� ✓ No. / v Fee Arc I� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopogal *pgtem Cou!5truction Permit y- r Permission is hereby granted to _ j m Ar/��'' (fO%j to cons ct(1/Sre air( )an On-site Sewage System located at �f .� ;K �./ -- _ . i and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. �4 All construction must be completed within two years of the date below. Er Date: �l Approved by w v TOWN OF BARNSTABLE LOCATION SEWAGE # I VILLAGEA.a==99ESSOR'S MAP & LOTO'yZ-& �:. INSTALLER'S NAME&PHONE NO._ <felollj ('Brl�l`— .771'9399 j SEPTIC TANK CAPACITY S� LEACHING FACILITY: (type) TC4 —(size) y X ,A30 NO.OF BEDROOMS 3 BUILDER O WNER a 7/10'42 PERMITDATE: �'Z6 . 6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching'Fac-ility Sf Feet Private Water Supply Well and LeachingFacility ty (If any wells exist _. I on site or within 200 feet of leaching facility) 1711# Feet j. Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet ofhing facility) Feet Furnished by - — I i I � . -53 s� �17 / 43 - APPLICATION FOR PER(�OLATION TEST AND OBSERVATION PITS t14P LOCATION r�ailb� �^ive NO. VILLAGE � DATE , APPLICANT FEE —4 ADDRESS -3/g ` , TELEPHONE NO. (Non-refundable ENGINEER E TELEPHONE NO,. -77S_Z244- DATE SCHEDULED 2_Noor.� (Applicant's Signature) • . .. ASSESSOR"S MAP & LOT NO: ................................. .......**"**............................................. lylq� '77� o�9,1eCdr4 7-6 SOIL LOG SUB-DIVISION NAME DATE JIJ(y 25 f ?7 TIME &Ico.? EXPANSION AREA: YES _X NO S, A , CJ,'/ - ENGINEER TOWN WATER _) PRIVATE WELL L^� 13�.�, BOARD OF HEALTH EXCAVATOR SKETCH:, (Street name, etc., dimensions of lot,.exact location of test holes Rn.d percolation tests, locate wetlands In proximity to test holes) NOTES: i �Cr,ZryS LATION RATE: ctl v., ' HOLE NO: 7P*i ELEVATION: TEST HOLE NO: 1-P"z_ ELEVATION: iner.Zo.� L 6$1 •f — f.Or12o - `ri 2 'B ' ho r I soh 3 Z4" 3 4 4 5 5 pt-2G �2.✓nin�.kti) moo" 6 6 7 7 S fO Sot�Q (3 Inc �m.ovcL 8 ��se Gi+a✓t/ t 9 9 10 10 11 11 �.Uo ��.,� 12 �/V, c.A4� ..��.�.., 13Z 13 194" 13 14 14 15 15 16 16 XBLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHES�_ ;TABLE FOR SUB-SURFACE SEWAGE. REASONS : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION 13[HAL: COMPLETED IN ENTIRETYY .P_L_ ,E. AND RETURNED TO BOARD OF HEALTH RETAINED BY APPLICANT �� vI f 1 20' MINIMUM OR AS INDICATED ON PLAN NOTES: a — lo MIN. 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.Q.E. MASONRY EXTENSION To 6• TITLE 5 ; THE TOWN OF H �Z�� s RULES AND TOP of FOUNDATION sELow GRADE REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE; } 53.5 e MIN 5 AND THE REQUIREMENTS OF THIS PLAN. A* c• � - 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO cr �"" - �s- 1 WITHIN 6" OF FINISHED GRADE. . 4- . PI 40 PVC PIPE 3. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE 4� e MIN. PITCH 1/8• PER FT. - = ' SHALL BE MORTARED IN PLACE. tl � Flow lM1E 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE +ass . '. +"• , K, CH 10' TEE SrE TeZE�I/C. , /Cod/ 44,3 co OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR . 3' MIN. WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADINGLEVEL -. I 4'-0- qg •- �8 3 SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR . t � z' MIN. , LIQUID PARKING. DISTRIBUTION LEVEL Box 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED Yr? •, RESTRICTIONS OR ZONING REGULATIONS. OWNER/APPLICANT SHALL F 6' CRUSHED OBTAIN SUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY. LOCATION MAP GALLON SEPTIC TANK STONE BASE z_ 6. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE ASSESSORS MAP i PARCEL 3�-6 & WAGNER FIELD NOTEBOOK #�o��+p LIQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW LINE BOTTOM OF TEST HOLE 4 FEET 14 INCHES OR USGS PROBABLE HIGH WATER LEVEL 5 FEET 19 INCHES 6 FEET 24 INCHES CURRENT ZONING INTERPRETATION: DESIGN CALCULATIONS SEWAGE DISPOSAL SYSTEM PROFILE MIN. FRONT SETBACK 30 FEET NUMBER OF BEDROOMS 7�k r:.L NOT TO SCALE 44. MIN. SIDE SETBACK 1 S FEET GARBAGE DISPOSAL UNIT TOTAL ESTIMATED FLOW MIN. REAR SETBACK 15 _ FEET ( iia GAL./BR./DAY X � BR.) 33 o GAL. /DAY REQUIRED SEPTIC TANK CAPACITY .:F GAL. COV64 9",%fiti -34",&fAX ACTUAL SIZE OF SEPTIC TANK /55oa GAL. PERCOLATION SOIL TEST CP- 8536 LEACHING AREA REQUIREMENTS ALLOWABLE PERC RATE= 0. 74 GPD./S.F, DATE OF SOIL TEST 2 S 7 14e 1cr5 S SIDEWALL Z (C3o xz, Z x 0.14 GPD/SF = 177 GAL/DAY ,7 SOIL EVALUATOR �� w. !fan �- I Str�DS7�N£ BOTTOM Z �.-ao x 4 1 xlZA GPD/SF = 177 GAL/DAY WITNESSED BY - a a + PERCOLATION RATE Two MIN./INCH z o i a 4s_ SF ..3 54 GAL/DAY io ib * - TEST PIT #1 TEST PIT #2 BREAKOUT CALCULATION: _.�-- -- ELEV.= 5 4.0 ELEV.= —• 4.0 ,r ^A' tio�,-toa -10.�00 .�.� —0.00 . _ b 3 Kox zo°a 10• H ZCw1 z4 " —2-4 /rllVEr2> `4)/c'!id X Z6%z x su' CL-1/7"ACTo,� P1_AS7"rC (. 4C��i,l/Gi G,=JA�✓/gMKS PEA T/EEh/Cij 5i. .+,�,�.��1 SFrih{,.UG 50.41 ;x.Ka E FFm L Firnc Co rAJ�-I LEGEND : i EXISTING SPOT ELEVATION OOXO EXISTING CONTOUR-------00----- �` FINAL SPOT ELEVATION 00.0 Nc \N�.1•e. ) �4 I ''z w�164"1 u1•0r,C• FINAL CONTOUR ---- - --------•— _ , _ � �L - 4G.c� BOTTOM OF TEST HOLE BOTTOM OF TEST HOLE SOIL TEST PIT LOCATION ELEV. 42.0 OR=ylA ELEV. 17.0 TOWN WATER ===W W SEPTIC TANK r`_o DISTRIBUTION BOX ❑ WATER LEVEL ADJUSTMENT: 3 o .+ - s — 7R6NCN 4r TEST DATE WATER LEVEL 4 INDEX WELL --- - - _ t2 WATER LEVEL RANGE ZONE - - - - ,- INITIAL ISSUE Airy DEPTH TO WATER LEVEL FOR INDEX WELL NO. DATE DESCRIPTION BY FOR MONTH OF: — — - - WATER LEVEL ADJUSTMENT 5 rz e-r ►c- -- — - i��s erR✓�► _.... --_..J DEPTH TO HIGH WATER Ao r C-> / /r1,qr,QL"A*jo ,(fir,rC- 9"4 w �I -' + �D NG h+ILL CO,'r A' APPROVED: BOARD OF HEALTH cy STEPHEIW " ' ALLYIV ,SITE PLAN y - SCALE: As ,vo,te.� JOB N0. 17 6 t < ,� No.3C�21S,Q DATE AGENT w- .e_ Eon,tfF�`��+. �`•'s* 1 so LEVY, ELDREDGE & WAGNER ASSOCIATES INC. PERMIT # Drees tat In ac13tT m Pumm IAID stIRymis 586 STRAWBERRY HILL ROAD. CYNTERV=, MASS. 02632 USE L i we —�� — t � � �— ca ��7 el f o o - �53 LOT 7LOT �- / �..� ti x i��T�NCy 3 W16E / \ pro pobC.x i �0 / JT0, VF CD \ �° /164 / ens 11 / / 61- �C-1 co SOT o O\JE A�REN S NOTES : 1) Plan Ref. - L. C. C. 23111B 2Datum --- ti. G. V. D. � -- -------- -- I ) l3) Refer to 2nd Sheet for Details 1 12/5/95 _ INITIAL ISSUE _ _ SAW NO. DATE � DESCRIPTION _ — BY SITE PLAN & SEPTIC DESIGN IN 0 S TER` II-,LE , MAS S AC HUS ETTS for LONGHILL CORP . SCALE: 1 " = 40' JOB NO. 1761/1761TOPO s� �, ►ow 4� STEPHEN �6 X ALLYN 0 40 80 120 s Sc.c A j WtLJ y .y ---- No.33216 LEVY, ELDREDGE & WAGNER ASSOCIATES INC. ENGM'FRS LANDSCAPE ARCHITECTS PLANNERS LAND SURVEYORS 586 STRAWBERRY HILL RD. CENTERVILLE MA 02632