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HomeMy WebLinkAbout0024 MATTHEW WAY - Health 24 MATHEW WAY MARSTONS MILLS A 064 026 ti r 'I I i A a UPC 12934 RR 7 oo 2.1 a3Li ✓P�'4r ��.5�� �i�SluGS, �J� _ _ _ __ i f h� � 1 � �� �� � `� 1�q,"44 Day-oa.Co Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yt 24 Matthew Way Property Address Colleen Chace ='a Owner Owner's Name information is f` required for every Marstons Mills Ma 02648 11/10/2017 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 1a�11-7 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection VQ Company Name 74 Beldan Ln. Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further 7F7Date thority 10/2017 Inspector's Signature The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Loij i)VS Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owners Name information is Marstons Mills Ma 02648 11/10/2017 required for 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 dwelling located at 24 Matthew Way Marsons Mills is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 500 gallon leaching chambers. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 2 of 17 E t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �f 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The:system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal y to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-3113 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. City[rown 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: El ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is ,required for every Marstons Mills Ma 02648 11/10/2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions:' Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): pro gpd pro gpd t5ins•3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '( 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every MarstonMills Ma 02648 11/10/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d well 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 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 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: tank pumped for inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? size of tank Reason for pumping: overdue 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): t t5ins•3113 M 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 rt 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 5/1/2006 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) if tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 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 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 How were dimensions determined? tank pumped for 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.): tank was pumped at time of inspection and should be done again every 2 years for proper maintenance. Water level was even with outlet invert, tank was structurally sound and not leaking. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 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 Off Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): d-box was in good condition, cover is on a riser. 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: E t5ins-3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. C4rrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): I s.a.s. consists of 2 precast leaching chambers with 4' stone surrounding. Leaching facitlity was found to have 6"of standing water with no signs of past hydraulic overloading. Cover is on a riser. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Citylfown 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-3113 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 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Cityfrown 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 0 Pr :)' M0 1-- A 36 t31 Zia J),&D) AZ 132 7 SA.S ,+3 ►33 78 rb t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 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: 12/+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 # Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 24 Matthew Way Property Address Colleen Chace Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/10/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Page: 1 of I CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 11/21/2017 Colleen Chace Order No, G17104079 24 Matthew Way Marstons Mills, MA 02648 Laboratory ID#: 17104079-01 Description: Water-Drinking Water Sample Sample Location: 24 Matthew Way,Merstons Mills Collected: 11/1612017 Collected by: Customer- Received: 11/16/2017 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen ND mg/L 0110 .10 EPA 300.0 LAP 11/16/2017 Copper 0.18 mg/L 0.10 1.3 SM 3111 B LAP 11117/2017 Iron ND mg/L 0.10 0.3 SM 3111 B LAP 11/17/2017 pH 6.2 PH AT 25C NA 6.5-8.5 SM 4500-H-B DCB 11/1612017 Sodium 8.0 mg/L 2.5 20 SM 311 1B LAP 11117/2017 Total Coliform Absent PIA 0 0 SM 92238 RG IIH6/2017 Conductance 52 umohs/cm 2.0 EPA 120.1 DC8 11/16/2017 Attached please find the laboratory certified parameter list. Approved By: (Lab Director) NO=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375.6605 J Of CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Recipient. Matrix, Water-Drinldng Water Colleen Chace Sampled: 111102017 9:15 24 Matthew Way Received: 11/16/2017 10,37 Marstons Mills, MA 02648 Collection Address: 24 Matthew Way,Marstons Mills Sample Locatlon: Order*: G17104079 Desalptlon.. rtn Lab ID: 17104079-102 Date Analyzed: 11/1612017 @ 11:08 Sample#: Analyst yn Method: EPA 524.2 Dilution factor: 1 Comment: EPA 524.2 Volatile Organics by GC/MS e�si L alt Parameter I ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dlchlo��dlfl-uoromediane ND 0.50 Chloroform 1.1 80 0.50 Chloromethane ND 0.50 cis-1,20chloroethene ND 70 0.50--.- Vinyl chloride -015-0 cis-1,3-Dichloropropene ND 0.50.- ND 0*50 Dibromochloromethane ND- 0.50 Bromomethane ne ND 0.50 Dibromometh a'ne 0.50 i6�jlbenzene' 1,1,1-Trichloroethane ND 200 C.i6 ND- 700 0.50 1,1,2,2-Tetrachbroethane ND 0.50 Hexachlorobutadiene ND 0.50 ND 0.50 11 42-Trichloroethane ND 0.50 propylbenzene 11,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0150 AJ-Dichloroethene ND 7.0 0.50 iMethyl-tert-butyl ether ND O.So 1,1-Dld-doroEopeT. ND 0.50 Naphthalene ND 0.50 ND ND 0.50 n-Butylbenzene 0.50 1,2,3-Trichloropropane ND 0.50 n-propylbenzene ND 0.50 ,'11,2,4-Trichlorobenzene ND io- 0.50 p-Issopropyltoluene ND 0.50 1,2,4-Ttime"bpnzene ND 0.50 sec-Butylbenzene ND 0.50 12-1)ibromo-3-chloropropane ND 0150 Styrene ND 100 0150 1,2-Dibromoethane(EDB) ND 0.50 tent-Butvibenzene ND 0M 1,2-Dichlorobenzene ND boo 0.50 Tetrachloroethene ND 5.0 0.50 1,2-vt&4oroethane ND 5.0 0.50 Toluene ND 1000 0.50 1,2-DicHoropropane j ND 0.50 Total xylenes ND 100W 0150 11,15-TrimedMbenzene ND '-i.-50 trans-1,2-Dichloroethene ND 100. 0.50 11,3-Dichlombenzene ND 0.50 trans-1,3-DicNoropropene ND 0.50 1,3-Mchloropropane ND 0.50 rlchloroethene ND ilorofluoTT -6.5-0 n(� _ I 1,4-Dichlorobenzene ND 5.0 0.50 - etharte ND En 2,2-Dichloropropane ND 0.50 Surrogates %ReCOvered QC Limits(%)I 2-Chlorotoluene ND 0.50 L)-_Bro!�ofluorobenzene 107% 70 1 130 4-Chlorctoluene ND 0.50 ijLs% -4i-7-13o- 1,2-Dichlorobenzene-dol Benzene ND 5.0 0.50 Promobenzene ND 0.50 i8romochloromethane ND 0.50 113romodid-doromethane ND Brornoforml N6 0.50 Carbon tetradlloride - a. ND 5.0 I 0.50 16iiorobei�ene ND 100 0.50 lChloroethane ND Attached please find the laboratory certified parameter list. Approved By: (Lab Director) ND-None Detected' RL = Reporting Limit MCL=Maximum Contaminant LM 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 24 Matthew Way Property Address Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist.at the end of the form. Important:When A. General Information filling out forms N z on the computer, 0F fLj,9sS�i,�i�.•• use only the tab 1. Inspector: ''•'9 '� key to move your I cursor-do not James D.Sears �iJ = • JA M ES R, key-usethe return Name of Inspector :4 z* CapewideEnterprises,LLC ,,• oo '*� my Company NameILAF 153 Commercial Street �0jF 5 I N SPE 0'` Company Address Mashpee MA 02649 City/rown State Zip Code 508-477-8877 S1623 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ fails ❑ Needs Further Evaluation by the Local Approving Authority 11-16-13 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. tsins•3113. rifle 5 offldal - :Subadace D'isposal Syst age 1 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owners Name information is required for every Marston Mills MA 02648 11-16-13 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: 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 exfrltration 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•W13 1 Title 5 Mist inspection Form:Subsurface Sewage Disposal System•Page 2 or 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms.not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a.manner which will protect public.health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 official Inspection Form:Substufaoe Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official 'lnspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an.overioaded 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 Is less than 60 below invert or available volume is less than %day flow eA clll vG t5ins•3M3 Title 5 Official won Form:Subsurface Sewage Disposal System•Page 4 of 17 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. cityrrown state Zip Code Date of inspection B. Certification (cunt.) 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 N 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 aftached 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 31.0 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 11 of a public water supply well if you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large "system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Mina-3/13 Title 5 Of el Inspection Form:Sulaurfsoe Sever Disposal System-Pape 5 or 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityfrown 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): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 l t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. tank D.Box and two 500 Gal.chambers. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage well water 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial 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•3J13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Pepe 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owners Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityfrown 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: 5-2010 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/Altemative 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-W 3 Title 5 Of ft Inspectlon Forth:Subsesce Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments. y 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed (if known)and source of information: 2006 Permit # 06- 170. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"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.): Pipeing is 4" PVC SCH 40. 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 i Dimensions: 1500 Gal. Precast Sludge depth: 2" t5ins-3/13 Title 5 trridal Inspadbn Fonw Sutlsurfaoe Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" litScum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-TapeSludge 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.): Tank at working level. Tank and cover's at 6"below grade. Inlet baffle,outlet tee. No sign of leakage or over loading. 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-3113 + Tine 5 Official lmspection 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 24 Matthew Way Property Address Amy Charron Owner owners Name information is Marston Mills MA 02648 11-16-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16"x16"-35"below grade w%over at 18". Box is clean and solid w/two lines out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 TO 5 trBdal Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is two 500 Gal. dry well chambers 13'x25'. Chambers are 40" below grade w/cover at 10". 4"water in chambers. No sign of over loading or solid carry over. No high stain line. 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•3113 Title 5 Official Inspection Form:Subsurface Sempe Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `< 24 Matthew Way Property Address Amy Charron Owner owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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•3f13 Title 5 QMdd Inspec Uon Form:Subsurfooe Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is required for every Marston Mills MA 02648 11-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 ��V 0� �l = y3_� 3--1 R EAR nD E e k U O ao ) O t5ins•3113 Title 5 Otflaal Inspector Fern:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Matthew Way Property Address Amy Charron Owner Owner's Name rnquired fo is Marston Mills MA 02648 11-16-13 required for every page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells r/a Estimated depth t high ground water 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: 3-23-06 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: Abutting property and area. T.H.on design plan 3-23-06 12'no G.W.. Bottom of chamber's at 5' below grade. Bottom of chamber's at T above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t51ns•3113 We 5 Official inspectlon Form:Subsurface Sewage Dlsposel System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 24 Matthew Way Property Address Amy Charron Owner Owner's Name information is Marston Mills MA 02648 11-16-13 required for 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-3/13 Title 5 OfBdef►nspeadon Form:Subsurface Sewage Disposal System-Page 17 of 17 TOVTN OF BARNSTABLE 11 LOCATION n1Z.�rim,J wzv SEWAGE # a( 17 U VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME,&PHONE NO. "r�C. S S C��� SEPTIC TANK CAPACITY` 1560 LEACHING FACILITY: (type) C6 )er.S (size) SZXGTP.l i3 K ZS NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: ,5 L° 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 p� LIT 4, r F No. 2. r0 C 70 Feel) - - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYtcatton for Mtgofsar *pgtem Cow9tructton Permit Application for a Permit to Construct( . )Repair )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Z Y *f0IL 9(.�pL�v, �/( Owner's Name,Address and Tel. -No. , Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.Imo. �QiCS1cJ£Ng lr- Q.✓rc�cfL4''t l� Po.�x �i MHQ��a�S ►mot g ,tad'-�{LP-3�6 Z- o� Type of Building: Dwelling No.of Bedrooms 3 Lot Size Z��� sq.ft. Garbage Grinder(tin Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 gallons per day. Calculated daily flow ` ` gallons. Plan Date 4�4/06 Number of sheets Revision Date Title Size of Septic Tank jEX /.SSo D Type of S.A.S. 14 e-i Description of Soil 4- Nature of Repairs or Alterations(Answer when'applicable) AZZ ��lt!►�L`/0� ✓ p Is-3 D-,QA bl- b�_/O " 2- y- vJIV v 5 t�Gv/ i.,V,4 Y PZZX:n� et.kj 6!:jd Z l / ,XZ Zt-tk t 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo Health. Signed Date IZ Application Approved by 5�-- Date 14 16,b Application Disapproved for the following reasons Permit No. 260 60 Q Date Issued �� /No: n /�� - Fee�S -� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for Mgogal 6pgtem Construction Permit Application for a Permit to Construct( . )Rep ' ( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 y wr,����y�„ Owner's Name,Address and Tel.No. kAeMj Cf/,4aeo Assessor's Map/Parcel 06 y—Q7� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C Q� C �tJCNS G . #k ✓✓,t.,f t`o n !ems �c�.P;px i �ti�a=�cz�,7��, �, t �S \ Cam, 7 rr ct 1 �c'1'- cl 2 C- Y6 Z Type of Building: Dwelling No.of Bedrooms 3 Lot Size 3�loy sq.ft. Garbage Grinder�q Other Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures Design.Flow 7 3 U gallons per day. Calculated daily flow 7 S-r gallons. Plan Date N /4 /06 Number of sheets Revision Date Title Size of Septic Tank FY / 70 y Type of S.A.S. Z Soy 5 c 1, h e-j t,./ Description of Soil Y'//2 4-7 Nature of Repairs or Alterations(Answer when applicable) t rw /6 a �� C/C/ e A-/U 1-0 U S 4/16ram C If e ./ Dat6last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo .dx f Health. Signed Date Y e- hi Application Approved by s+-- Date 01& Application Disapproved for the following reasons ttt � Permit No. D -7 U Date Issued y l q tab `• - - - -THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS . o 6 1_ 71— ` Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired (--,),",Upgraded ( ) Abandoned( )by ' at of 7,!/ la4 /4L.w 14-4, 41 Cry ) --U, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.' f�n , �� dated Y 1i.12 /� Installer � un., Designer }-��G The issuance of this permit 4tll no be construed as a guarantee that the system will functa as ldesigned. Date Inspector No.� ,�7n --------------------------Fee l 00� .. THE COMMONWEALTH OF MASSACHUSETTS U G 11-0 6 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Xi9;po5a1 *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at / and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date:_ /cg t� Approved by i� ` p P��IL 'vA l 12'-0. 9434 3u! o r/ 0NEW o � BATHROOM EXISTING HOME O NEW ADDlTIIbi-jVg �y EXISTING HOME FIRST FLOOR PLAN �S -a Qy 34-0' '-0' 10'-6' 6'-0' O0_ W o o AD o 0co N y� N v N 0 N o o I A e � O aTO "SECOND FLOOR PLAN a" "° Xs r Town of Barnstable [regulatory Services Thomas F. Ceder, Director 9 b& Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 installer & Designer Certification Form Date: _ AA Sewage Permit# Assessor's Map\Parcel 66Y 00i�o Designer: - _ �j�6Lrrrn �vr�.5, Installer: 1�_ Address: ) L aGPa )-e La.„�eY-- Address: _P-0- bwc"l l -- N�Gt�Jf7v,J /1,//� 4W 0U41 MKaToNS tAILLS Auk. On was issued a permit to install a (date) (installer) septic system at L`j / �Y .✓-k/ based on a design drawn'by _--- - -Ll a -(address/------------- dated Mql( o G a certify that the septic system referenced above was installed substantiall3^accordi.ii'g to cr the design, which may include minor approved changes such as lateral reWation orthe A distribution box and/or septic tank. Esi -- = _=3 l certify that the septic system referenced above was installed with major c anges ;e. greater than 10' lateral relocation of the SAS or any vertical relocation of any omponent of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-bull[ by designer to follow. 5�(lnstf ZN OFGLEN__ ERIC er's Signature) HARRINGTON No. 1070 QTAVj\ (Designer's gnature) (Affix tesigner's Stamp Here) r PLEASE RETURN TO BARNSTABLE PUBt.IC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT 8E ISSUED UNTIL BOTH THIS FORM AND AS-BIJILT CARD ARE RECEIVED BY THE:BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:I fealth/Septic/Designer Certification Form 3-26-04.doc Town of Barnstable P# I� Department of Regulatory Services L13VT Public Health Division Date tb �� 200 Main Street,Hyannis MA 02601 - ?R� FE3 23 kM IC* 37 Date Scheduled3 ' Time �'l Fee Pd. ' SION 'Soil Suitability Assessment for Sewage D s oral Performed By: �r� P- He. �s`"6v h. � S. Witnessed By: � n LOCATION& GENERAL INFORMATION Location Address //,,,, Owner's Name Cj#,41Zt"'V,/4-h Y+ 160 � W� k A 1 Address g� rv.e S Assessor's Map/Parcel: � O uo Engineer's Name (q E• r/ • ton ZS• NEW CONSTRUCTION REPAIR Telephone# STJB'�Z 38(9 Land Use d+A.f- . tSlopes(9'0) 0 '3 Surface Stones w 0 Distances from:, Open Water Body � Z�o ft,- Possible Wet Area �2� ft Drinking Water Well Drainage Way �G O ft Property Line v 3 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) .01��; +flPy P ®�7'// Q V�(,v�t o Parent material(geologic) Depth to Bedrock >L 00, Weeping from Pit Face ��Je Depth to Groundwater. Standing Water in Hole: Q P 8 -T - r---- Estimated Seasonal High Groundwater Y o' " "' 9 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Obscved star ding in obe.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole: min, Groundwater Adjustment fc. Index Well# Reading Date: Index Well level�. Adj,factor Adj.Groundwater level PERCOLATION TEST bete Zl 'line <0,__�_.?° Al Observation f1 L Hole# Time at 4 Depth of Perc �q Svc y 7 Time at 6" _ .. Start Pre-soak Time @ 3_ 71me(9"-V) -- End Pre-soak 0 Gf Rate Min./Inch ' n al ling I Site Suitability Assessment: Site Passed Site.Failed: Additional Testing Needed(YM) Original: Public Health Division > Observation Hole Data To Be Completed on Back----------- / ***If percolation test is to be conducted within 100'of wetland,you mustIlrsCnotify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:�SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistencv. ray fo y2f/3 3 L S l d.YAr-6 tin 3 �- 7.O C 1 ��e-cf Sow.d z.s'y7/y .vo Gw E DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) 0- q GS /0r4r1 Q Sr F. 3 y- to (/ w-c fd •r.Y 7/f 777=— DEEP OBSERVATION HOLE LOG "'' Hole# Depth from Soil Horizon Soil Texture Soil C61or Soil`: Other Surface(in.) (USDA) (Munsell) r/Mottling (Structure,Stones,Boulders. Con i to c %Gravel) i` t i / i ,r�l l • , i; `. M;�;r-{'., ,�; yam:; _ .• DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Surface(in.) Consis e t 1 i i - Flood Insurance Rate M812: Above 500 year flood boundary No— Within 500:year boundary No= Yes Within LOO.yearfloodboundary No Yes '•'. , Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious materia fexi`st in alkareas observed throughout the area proposed for the soil absorption system? y ± ` ' If not,what is the depth of naturally occurring pervious material -- Certification I certify that on 1 d 9pS (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and eyperience described in 310 CMR 15.017. Signature Date Y G Ot0 Q:\SEVn0PHRCr.ORM.DOC I BORTOLOTTI CONSTRUCTION, INC. S w 4 INDUSTRY R MILLS, 0264 k ft 5 IND Y ROAD, MARSTONS L S,MA 8 .�,_r O f gNS 508-771-9399 508-428-8926 FAX: 508-428-9399 �FPj TgacF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 t�ERTIFICATION Property Address: Date Of Inspection S Inspector's ame: Owner's Name and Address:2U46 2 ,&-d��Yo MA 00696 ---- CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true, accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.Tpe system: I Passes Conditional sses Needs F. .th Eva By the Local Approving Authority Failure Inspector's Signature Dater Q The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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. INSPECTION SUMMARY: A) .SYSTEM PASSES: I have not found any Information which indicates that the System violates any of the fail-. ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System, upon j completion of the Replacement or Repair,Passes Inspection. . Indicate ves,nor,or not determined(Y;N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- .tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming 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 Svstem will pass Inspection if(With Approval of the Board Of Health): -1 - Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. A CERTIFICATION (continued) Broken pipe(s) replaced Obstruction is removed Distribution Box is leveled 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): Broken pipe(s)are replaced Obstruction is removed. 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 it' the System is failing to protect the Public Health,Safety and the Environment.. 1) SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a Septic Tank and Soil Absorption System and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public Water.Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and 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 from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: ` 1 have determined that the System violates one or more of the following Failure Criteria as defined 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. Backup of sewage into facility or system component due to an overload 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 clod- ged SAS or,cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is.less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd 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: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ,ZNone of the system components have been pumped for atleast 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. Ts-built plans have been obtained and examined. Note if they are not available with N/A. he 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 site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition 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 or approximated by non-intrusive methods. - 3 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS v RESIDENTIAL: Design Flow:-3_3Q _gallons Number of Bedrooms: 3 Number of Current Residents: Garbage Grinder:/)Ltj= Laundry Connected To System: Seasonal Use: Water Meter Readings,if available: Last Date of Occupancy: C'OMMERCIAL/IN1DUSTRIAL:/K4- Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: 7— System Pumped as part of inspectionj/X� If es,volume pum d: gallons Reason for Pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If es,attach previous inspection.records,if any) Other(explain): s APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage ddors detected when arriving at the site:� �Y ° -4- d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK:_ Depth below grade: Material of Construction:�� concrete metal FRP Other (explain) Dimensions: 5'x(p'X 5 Sludge Depth: 6o Scum Thickness: a'' Distance from top of sludge to bottom of outlet tee or baffle: 3 7 Distance from bottom of scum to bottom of outlet tee or baffle: /j Comments: (recommendation for pumping,conditioin of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evid nce of leakage,e c.)w0y GREASE TRAP:�.�� Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacitv: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:ZL�- Depth of liquid level above outlet-invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:/-&a— Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):_ (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) .If not determined to be present,explain: Type Leaching pits,number:_ Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments:(note conidtion of soil,signs of hydraulic failure I vel of ponding,condition of egetation,etc.)_ 07� , CESSPOOLS Number and nfiguration: 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: Materi Is of-construction: Dimensions: . Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) = 6 - a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. j j j Coo DEPTH TO GROUNDWATER: Depth to groundwater: 3 Z Feet Method ot_Mterminaoon or Appro 'mation: /r fir zi®w Du lv - 7 - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 6G0/, Parcel 6cP �,7 Permit# <. Health Division d ^ � Date Issuedy M a2£`" Q2a $ I �r Conservation Division �0 Fee Tax Collector O 5 Treasurer Application Fee Planning Dept. Checked in By Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis Project Street Address � � el ) U-)AV Village _A�t_5_(6 at l tS Owner. . ER roy1 Address IM04 een-1 Qt? 410-7 S W1'f( I Telephone -{� p rcp r P Permit Request R��.X,��._a x l Y add c`�r w� 9-0 J e�e� C= c Square feet: 1st floor:existing proposed f(or 2nd floor: existing 2 3G proposed fi .Totalew ca Valuation Ar-0 Zoning District _ Flood Plain Grou r e' y Construction Type W AV�,,Ww Lot Size Grandfathered: ❑Yes &/No If yes,attach supporting doc atioF Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: UrFull ❑Crawl ❑Walkout ❑Other I Basement Finished Area(sq.ft.) ®©" Basement Unfinished Area(sq.ft) q 3 W Number of Baths: Full: existing 01- -new .2 Half:existing — ® - new — ® r Number of Bedrooms: existing 3 new Total Room Count(not including baths): existing 69 new First Floor Room Count y Heat Type and Fuel: ❑Gas 10 Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing / New / Existing wood/coal stove: ❑Yes ❑No Detached garage:Cl existing ❑new size Ind Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size 00 Shed:Cl existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name LL) l �>c kQL zA?A Telephone Number /(5Y 53_ Address s0 License# ® Ll'� �?7 VD 2� 3 6 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �,�/e�`7`s DATE !/© go- -Z x A101 iol L9 el3II II II Q NEW 0 "LimOO ' �I F BATHRM EXISTING HOME 0 0 + Q NEW ADDITMN;py o c �.� EXISTING NOW FIRST FLOOR PLAN "v4's-p ID.n (� - Y a 34'-0' 8'-0' 7'-0- 00 W o /J o r\1 iflJ �• o N v ❑ n�� c N e o N N p o ' 1 4 SECOND FLOOR PLAN 4'g l � Tt de— ,a.rc NoFM Dwnn NmMI WNRECI f ro a a o lV N Tr El NIUaaa® 0 u�uM o0 00 C�� 0 ,o-.ot 66q No. - Fee— - - OARD OF HEALTH TOWN OF BARNSTABLE Application for Vell Cootruction Permit n .Applicatio,�j is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( �n individual Well at: -- Lo ation — Address Assessors Map and Parcel A4 AA Owner -Address w� l0rr _ �o /�oX it'o �p iwa -- - - -- - -- - Installer — Driller -- ---- Address Type of Building Dwelling 42tAi e --- ---—------ Other - Type of Building------------ No. of Persons---------------------- r Type of Well Y` hoc — Capacity-------- ---- Purpose of Well- QQI -ec fi% -- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed —___— —_— IC) date Application Approved By ITIV ---- ---- C. date Application Disapproved for the fo owing reasons: ---------------- -------- -- date Permit No. — Issued-------------- -- — ---- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERTIFY, Tha the Individual Well Constructed ( ), Altered ( ), or Repaired (/-T by— — �J� -�-} Installer at �6 , MaGGaw (aa�( titr,f K�/S has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----------Dated---- ----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- - Inspector—__----- - -- -- —------- No. Fee— - --= --- BOARD OF HEALTH TOWN OF BARNSTABLE V f ti Applicaon or ell �tCongtruconPermit t ti . n • Applicatiois hereby made for a permit tn//Construct ( ), Alter ( ), or Repair ( �n individual Well at: AA I lIS Location —•Address Assessors Map and Parcel rA AA Owner— -- -Address----------------- --- Installer — Driller Address Type of Building Dwelling --------- Other - Type of Building----------------- No. of Persons----------_------------ Type of Well y t (06 -- --- Capacity—_--— —------- — Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation The undersigned further agrees not to place the well in operation until a Certificate of ompliance has been issued by the Board of Health. Signed — — 1J oat— ---_-- date Application Approved By date Application Disapproved for the fo owing reasons: ----------- - ---_-- —_ - _ .-- — ------------- date --- Permit No. -- -- Issued-----_-- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY ATh t the Indiyidual Well Constructed ( ), Altered ( ), or Repaired (� by---------- —--- Installer ---- ———— -- — — has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. --_--_---Dated---- ----= THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - Inspector r I BOARD OF HEALTH TOWN OF BARNSTABLE 1- 'Vert Construct ion Permit I� 0�0004/ No. -- -- Fee_�__-- Permission is hereby granted to Construct ( ), Alter ( ), or Repair ( 11) an Individual Well at: No. /G /`«�Grw �'G� /kc� y`u.r M ,/S Street — — -- ----------------------- as shown on the application for a Well Construction Permit No.- — — Dated— — =- — --------------------------------- /� -- — Board of'Health DATE / (�' THE COMMONWEALTH OF MASSACHUSETTS ,BOAR® ® HEAL.�T' V , ....OF............. . . . . _ ....... Applirativit for 13hipfial Works Tonotrurtion Urrmit Application is hereby made fora ermit to Construct ( ) o Repair ) an I dividual Sewag Disposal �j syst t...... ....�i..... .. ................ ... .. .,. •� Location.Addresi o Lo 0 ... t 1..f..> . ... ...... . .. ✓.. e st.. .... rn,a wner ............. .. ddress� .. .......... ./ ller Address dType of Buildi Size Lot.. .._�l..(P- __Sq feet U Dwelling No. of Bedrooms................... -Expansion Attic ( ) GarlSage Grinder ( ) '4 Other—T e of Building ............... No. of persons.....__._......_...._...._.. Showers — Cafeteria a' Other fixtures ... ............................................................... W Design Flow:................................... lions per person per day. Total.daily flow.__.........^.. ....._..._...._.....gallons. 40 WSeptic Tank—Liquid capacity.----..._ allons Length'................ Width---------------- Diameter................ Depth................ Disposal Trench—Fo..................... Wid f.�Total Length......... _ Total leachingarea..... s . ft. Seepage Pit No____ _______________ Diameter. Depth below inlet_.... ..... Total leaching area.._: ft. P g q Z Other Distribution box ( ) Dosing tank ( ) Percolation Results Performed T _ Test Pit No minutes perinch Depth of Test Pit____________________ Depth to ground water.______________.____._. fs, Test Pit No. 2................nunutes per inch Depth of Test Pit-------------------- Depth to ground water-___________-___. o {� tf- -- - - ------------- --------- Description of Soil [ - ----------"------- -------------------------- -- . ............. U ---- ------------------------------------------------------------------------- --------•-------------------------------------------------------------------------------------------------------- ................................................................................................................................................................................................ W VNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ed the board of health. Signed. . ... ............. ......... .. ........ .. ................... - Date j Application Approved BY-------- ... - •-------- ------- --- --• --• �/��✓�-----,----- ate Application Disapproved for the following reasons:.......................................... .................................................................... ••--•.......................•--------•--•---•-------------••--••---------•-•----..........-------••---------•- ----------•-•------•---------...-------•----.......... ................................ 7 Date PermitNo......................................................... Issued.-----.. f-•-�- •-•----•-•- No ' _.__._ Fes$ r.. THE COMMONWEALTH OF i4'ASSACHUSETTS BOARD . a,..o�•j1°'"' � ram :,r � �� � Application,is hereby made for a P�rmit to Construct ( ) or:-,Repairr'. . ) an��(h�Jrpdividual S�c�,}4g Disposal Syst 'at j�� / j 5 I fiY. �. �i f/' 'Ike 1..- , .., eV Location•�(A+ddress: !f { r orb ------e.a.e^ ddress �- QType of uildin � Size Lot__„ ... ......Sq. feet Dwelling No. of Bedrooms..........ti ......................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a YP g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( - ) Otherfixtures . r ----------------------------------------------------------------------------------------- W Design Flow___________________ � _.•... ...gallons per person per day. Total daily flow._-_...__ . 7' _ ___.gallons. WSeptic Tank—Liquid capacity./A.llons Length................ Width................ Diameter................ Depth................ x Disposal Trench— To ----•______________ Width .. s�Total Length _.. Total leaching area.__.. �. ft. Seepage Pit No.. _ _. � ............° ' s ft. __ Diameter _ ._._ _ epth below inlet .:_...... Total leaching area.... q. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.........................................................•_--------------- Date........................................ HTest Pit No. 1.. ----minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................. Description of Soil {, `. " '�". ------ U --•-•-•--...-•-••-......_._._ ..••......................... --•-•-..........__...... ... ......._......--•------•-•-,_---- W -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------............... U Nature 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 Article YI of the State Sanitary Code—T e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been;rssped the boat of health.. �_ s Signed "j .............. Dater Application Approved By._.:: ,, x�- �. -- _._ td ...ate ro - Application Disapproved for the following reasons---------- ------------- --.--- -- ------ ---•-•--...._..----••..................................... ....................••---............•---•-•......._.....•--•-------------------.....--••------•••-•••-•---•--------•--•---•. --•-•---------------- ------------------------•------------ Date Permit No....................... Issued-' �.//. ... ... . ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OFIEAL,TH .........OF....... ......:.- , � . iratr Lit Toutpliana „ RT�T �, at i f ividual Sewage Disposal S stem constructed (+�") or Repaired ( ) 11!f gip. has been installed in accordance with the•provisions f Article 1I of The State Sanitary Code as de�cti red the application for Disposal Works Construction Pernat No__________________ � � '" PP P - '° dated . --.- ---� , �- " THE ISSU, NC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A C�IJA�AN EE THAT THE SYSTE': I -�1"9'N SATISFACTORY. DATE...... ---•----- --------- --------------------------------- -----........... Ins ecto ...... ---------- THEO OF MASSACHUSETTS r BOARD F HEALTH y ,s Q .............OF....... L�..�..._ ..w a.........(..-. ... . ., ^r"f NO..... .. .. FEE.......... ......... Dilia Vor 041fi $Oat. Permissio herebyrante � . � .. to Constr l or R �i tit s �)�, e�'i t. � )�aii �idrvidu��l Setilfage Disposal S°'itemat:NO.. Ai; .... ... ' ' `�'k :Sei . '— �': : ............f �r 2 , r� ......_._. ' > t Street f! as shown on t application for Disposal.Works C011S�I ction Perr4frtNo. ated_.._. - .�'- -- r .......... ... ` ^' * l- trd of I alth DATE.......-_.... .----•........:....•---.-...----------- ._............ �,... FORM 1255 HOBBS & WARREN, -INC_„ PUBLISHERS - s Design Calculations N SITE PLAN Number of Bedrooms: 3 Existing SCALE: 1"=20' Garbage Grinder: NO, GRINDER NOT ALLOWED WITH THIS DESIGN - a Septic Tank Capacity Required: 330 d X 200% = 440 d ¢ Debora BENCH MARK ON TOP CORNER of P • P Y q 9P 9P � h Wa � CONCRETE BULKHEAD ELEV.-100.00' ASSUMED Septic Tank Provided: 1,500 gallon EXISTING z 3a Leaching Capacity Required: 330 Gal./Day Q o Leaching Area Required: 330 Gal./(0.74 Gal./Sq.Ft.)=446 Sq.Ft. o Proposed Leaching Area Provided: 25 X 13 X 2.0 = 479 SQ.FT. 0 0 Total Leaching Capacity. 355 gpd > 330 gpd. req'd. � G EDDRESS: THEW N E R A4 MA NOTES W ARSTONS MILLS RACE LAN SITE 1.2. ASSESSORS NUMBER: 064-026 E = o 3. DEVELOPER'S LOT: LOT 6 ° 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN ° ON THE GROUND INSTRUMENT SURVEY. "MARSTONS MILLS" o 5. WELL WATER IS PROVIDED TO SITE & SURROUNDING PROPERTIES. LO C' 6. REFERENCE PLAN: LAND COURT PLAN 9484B - SHEET 1 �J 7. NO WETLANDS ARE LOCATED WITHIN 200 FEET OF SAS. 8. NO ABUTTING POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. SCALE: AS SHOWN 9. UNDERGROUND UTILITIES LOCATED PER DIGSAFE NOTIFICATION #20061200764. PERK TEST & SOIL EVALUATION 2c�66 TDATE OF PERC TEST & L V 2 2006 EST PERFORMED BY: GLEN E. HARR NGTON, R.S WITNESSED BY.- DONALD DESMARAIS R.S. HEALTH INSPECTOR EXCAVATED BY: AALTO LANDSCAPE CONSTRUCTION Test Hole Test Hole No. 1 No. 2 Q �O� os�eo P 1 1247 DEP SOILS ELEV. DEPTH SOILS ELEV. o s`0y 0 0 F Perk Test @ T.H. #2 5- LEAF LITIM 4- LEAF UI ` °'4 ''' i:'•E i'' ':': i'`•' '•i i E:E:icE:E•"•:• Depth to perk hole= 43" - 61" A A ;; :•:::::::::::::::E:::::::isEi::::i;E;:;:::i::::::6;E:::::. P b 24 gals added in less than 15 minute soak period 1arRs/a toYR4/3 97.04' :•.R/�', i''' ? i'i i i ':i;:i::?i i i::• ��- LOAMY Sara 97.5 8' lo/rrr S�nD 97.83 LOT 6 a Use <2 minutes per inch for design purposes Bw Bw 1orR5/e +orns/e � S 38' LOAMY SARa 95. 34' LOAM!SAND 21g ARE A A 2 33 00 Q .F T. c, cl MED.-COAM MED-COARSE Said sad 2.5YR7/4 ZS"7/4 CB fnd. NO GROUNDWATER ENCOUNTERED CONSTRUCTION NOTES °' 1. Contractor is responsible for Di safe notification �. .. �. .� �. .. . x 98.50' P 9 X 99 4' and protection of all underground utilities and pipes. 96.56' :: :� ::�`:�X`: 99,24• 2. The septic tank & distribution box shall be set �'�•��,�:��,�•��.�•�� tl level on 6 of 3/4"-11/2" stone. 9656' �� :� RESERVE 3. Backfill should be clean sand or gravel with no ca frd 'r/STj AREA stones over 3 in size. ISTING WELL `':� 4. This system is subject to inspection during installation utt►itiea �� Fd�C by Glen E. Harrington, R.S. +��/� ���•A 5. The contractor shall install this system ir. accordance M with Title V of the Massachusetts Fnvironmental Cndr r and EXISTING LEACH' ,BE 6. Provide an he ,.tgulations of the Town of BARNSTABLE. H PIT TO " DO PUMPED AND PIT LLED and 2-500 Precast H-10 DB-3 DitTRIBUTION BOX 0 gallon H-10 leaching chambers or equal. 0 7. No vehicle or heavy machinery shall drive over the 825' septic system unless noted as H-20 septic components. 8. Install gas baffle or equal on septic tank outlet tee end. r� 9. All existing inverts and site conditions shall be verified by contractor. 98.28' 10. BOARD OF HEALTH AND DESIGNER ARE TO INSPECT AND CERTIFY INSTALLATION. 11. The existing LEACH PIT shall be pumped and backfilled. TO- 5, 98.71 e-e' O• ` 1-20'DAM.ACCESS 61AMHOIF LEGEND �5` O ;..:.�. O 0k24- [34- PERK TEST LOCATION 2� C3 O C3 O C PROPOSED SAS r. ,..� ,• . �'r.:..,.. EXISTING 1500 GAL 1-25'L X 13'W X 2.0' D ry STEEL REINFORCED PKCW CONCRETE 2 H-10 500 gal. chambers 0 0 o H-10 SEPTIC TANK R.' leaching trench using 2 Q 1V PLAN VIEW END-SECTION H-10 500-gallon chambers X 104.46 SPOT DENOTES EX STING 6A y with 4' of stone all around. a a ��?, �yqr o10 H-10 500 GALLON CHAMBER 95 EXISTING CONTOUR N0 � X 99.16' NOT TO SCALE DEEP TEST HOLE USE ACME PRECAST OR EQUAL ,g0 •(O a M� `N PROPOSED WATTIONER LINE O a2 -��10FIyA�"s PROPOSED SEPTIC SYSTEM UPGRADE o� PREPARED FOR X 9997' o GT '50" J-EFFREY J. CHARRON ET UX 1070 AT a A sq-IS'(ti�P� #24 MATTHEW WAY *NOTE: ALL PIPES ARE TO BE 4" OIA. SCHEDULE 40 P.V.C. ae _. 'NV/TA'B BARNSTABLE (MARSTONS MILLS), MA house,to septic from *NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET Existing House Septla tank covers must Finished grade over syatem�2% clop* away within 6.of finished grad. PREPARED BY: Exisn of MST.Box Sox e �mguads,be Existin Grade Elev.=98.5'f GLEN E. HARRINGTON, R.S. D-BOX cover mud M Min. 2'-1/e•-t/2' ;min. I U J! + S 0.02' within 8•of finished grads double-.oehed clone mox , 9 LE DA ROSE LANE Cellar , ,�a"NG u� tar2 13 one Elev.=96.2 f 1' MARSTONS MILLS, MA 02648 SEPTIC TANK _ r o 0 0 0 0 2.•L.M Leach TEL: 508-428-3862 «s = P- 25' Trench Elev.= 93.73' FAX: 508-428-3862 3/4•-lS/2' LEACH TRENCH BOARD OF HEALTH VARIANCE Existing DOOBLE-wASH0 sm 5't r 5' R EQ'D 1 6'OF 3/4•-II /Y STONE E_ _ \ / SECTION 397-2: A VARIANCE IS REQUESTED TO ALLOW THE PROPOSED SCALE: 1 "=20' DRAWN BY: GEH APRIL 4 2006 Ec SOIL ABSORPTION SYSTEM TO BE 100 FEET IN LIEU SYSTEM PROFILE e•OF 3/4'-11/2'STONE OF THE REQUIRED 150 FEET SEPARATION DISTANCE. Not to scale BO M OF T.H. #1 ELEV.=88.50' DATUM: ASSUMED FILE: STEVENSMATTHEW SHEET 1 OF 1 Wd6Z'6V:69010- L �]!DV'd INIiNab'SJN1113SaNVS1N:�W(looa o-M-,