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HomeMy WebLinkAbout0002 MILL POND ROAD - Health 2 Mill Pond Road Marstons Mills P A = 063 052 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay use the return Name of Inspector key. Shay Environmental Services, Inc. ,� Company Name 185 Ashumet Road Company Address Mashpee MA 02649 City/Town State Zip Code =5 508-539-7966 _ 3080 Telephone Number License Number i B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the R information reported below is true, accurate and complete as of the time of the inspection. Theinspeetion was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evabwtion by the Local Approving Authority 7/7/10 _ Inspecto' 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. 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is Marstons Mills MA 02648 7/7/10 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: leach pit has 3' Liquid-4.5' stain line noted B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 2 Mill Pond Road,M Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): .❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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. 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into.facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water'supply. 2 Mill Pond Road,M Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 2 Mill Pond Road,M Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 2 Mill Pond Road,M Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e' 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 1.5.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 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: Last date of occupancy/use: Date Other(describe): - 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for ever Marstons Mills MA 02648 7/7/10 4 Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron 1 ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 5x 5' x89' - 1000 gallon Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 18" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition, inlet tee in good condition, outlet Baffle in good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 2 Mill Pond Road,M Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present 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 in fair condition. Some minor carryver noted. One outlet to leach pit. Liquid level equal to outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ® leaching pits number: 1-6'diam x 6' D ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ Innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS fuctioning properly, 3' liquid in pit, 4.5' stain line noted 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is required for every Marstons Mills MA 02648 7/7/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 2 Mill Pond Road,M Mills-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Name information is �„� M.�� MA 02648 7/7/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 16GEC 0 e � 66' 0 0 9 9 W No 20 2 Mill Pond Road.M Mills•03108 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Mill Pond Road Property Address Mr. Thomas McInerney Owner Owner's Nane information is Marstons Mills MA 02648 7/7/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+ feet. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Inspector has performed perc tests in neighborhood-refer to Topo Maps 2 Mill Pond Road,M Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 /io O of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. 6b ariv I e ' 6 r/ 1 `bA VP - !�� 2 �. C 2gCO v, P. 1 * COMMUNICATION RESULT REPORT ( NOV. 3.2005 2:17PM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 395 MEMORY TX 915087751117 OK P. 10/10 ---------------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address: 21VXXY.LL POND ROAD MAMTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sowage disposal system Including ties to at least two permanent reference landmarks or benchmarks, Loeato all walls within 100 thot,Locate where public water supply enters the building. ° Walk AF 0 r- pp ,Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS;MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. tau � �a 00 eA VW flob 2D 20 to COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED A ` \\\YIIIWW�III ✓ APR 2 8 2004 j Q TOVvw ur j, ir;dLE �7 — HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ©� cum Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 3 C. Owner's Name: ALICE WOOD Owner's Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Date of Inspection: 4/3/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS 40*p Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally es _ Needs Furth aluation by the Local Approving Authority _ Fails Inspector's Signature: Date: 4/3/04 The system inspector shall submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti . If the system is a shared system or has a design flow of.10,000 gpd or greater,the inspector and the system owner sh 1 submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copie sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Titlr S Imm-rtinn Fnrm 6/1 SOf1M 1 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 MILL p y POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the . for the following statements.If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a • Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped SYSTEM WAS PUMPED TWO YEARS AGO. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] S Page 6 of 11 a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use: (yes or no):NO Water meter readings, if available(last 2 years usage(gpd)): On C) Sump pump(yes or no): NO 2 Last date of occupancy: n/a J - �W(l COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: SYSTEM WAS PUMPED TWO YEARS AGO ye C O,_� Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no),(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 18 YEARS PER OWENR ' Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7"W 4' 10"" - Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. PUMP CHAMBER:-(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6'X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE.RECOMMEND RAISING COVER 41.PIT HAD 2' OF LIQUID IN IT AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 2' OF LIQUID IN IT.BOTTOM IS AT 10' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction:n/a Dimensions: n/a Depth of solids:n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a v r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. arAl JV IbA 0 6 �1 W ��Zq� "Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 MILL POND ROAD MARSTONS MILLS,MA 02648 Owner: ALICE WOOD Date of Inspection: 4/3/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER-12 FT. 11 No. ,��:Z F:zivS....�..............-� r' THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....................O F......................................................................................... Appliratinn for Diipnaal Worko Tonstrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_.... . .1...(........ .... ..................... ............................. -•---------------..._...........--Lwation-A ress o ............. ....' T � _ t✓ r1�% ......_.... - ------!�21 -''•--�-'............................--..... -- -••-- O n r A dress7mtc Installer Address ' dType of Building Size Lot------6 0 ''�_Sq. feet , Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building � �� 1iNo. of ersons..... .....__.___. Showers — Cafeteria w yP g ---•---- • -•• - P ( ) ( ) aOt fi ures ...........•----•......-•------• ------• ---------------------------...-------•-•--.... ...................................... W Design Flow....__.. �!-_...-��..gallons per person per day. Total daily flow.....�.,�•-...................gallons. WSeptic Tank—Liquid capacity/........gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date.._........_..•------------------------- aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ --------•-------------------------••----------....--------••---•-----------------------•----...__•--......................................................... 0 Description of Soil....................................................................................................-------------------------------•---------••-••••......•---......--- "� W ---------------------------------------------------------------------------------------•----------------------- -- _ ----- � i__6_Niy� r � U Nature of Repairs or Alterations—Answer when applicable_..__ __._.___ Agreement: 0?9-re 0 1'2� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance;witli the provisions of iIT :;�. 5 of the State Sanitary Code— The undersigned further agrees not to place the system ifi' operation until a Certificate of Compliance has been ' ued b --the health. ned..... ....... 11 --- ------------------------•• ... --... --• -------- e Application Approved By-•-- . •..... -` . •- ............................ ............ ------- ----fit ................. ate Application Disapproved for the following reasons:......................................................... ..... ,,, ........._. ...............................------------.....----------------•-----------------------------------•---••••-••----•••-••-•----••------••-•----•-•......------..••••----•----------••-••---••-.._._.... Date Permit No...... •-:..--•--•=--7------------••--- Issued---------==--•- •••••-•---•--•----•-------------•-- Date I b' . .No.46... Fx .............................. ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................. ................OF.........------..........................---...----...........----.._..........---------- Applirtt#iun for Eliipuutt1 Workii Tunitrnrtiun amit Application is hereby made for.a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ ................_..- -'� �. . � . ... =.... 's. - .`4: �g -••-•-------------•--...................-- ...e ..... .... �r ation-Agd�ryess { 1 r� (1 o Lotrlljo j,� - ... a�. 1 F � t' !YJd-!(C` #d_-[ft -•-•--•-•-------•---••---•- - -F-!•. !.r"(�7 Ui'E/ ......... 1------------- l�� ... .. ............................... 1 ,r roger a A,dress nM+ � � Installer Address d Type of Building Size Lot..... 2.0'_____________Sq. feet Dwelling_No. of Bedrooms.......... _..........................Expansio Attic ( ) Garbage Grinder ( ) Other—Type of Building ' ,t W. No. of persons_____ ___.___.____ Showers ( ) — Cafeteria ( ) aOt xtures ------------------•--••---•------•---•--••------- ------------------------ ..........W Design Flow_______ ,�_ _____________________gallons per person per day. Total daily flow____ _,2.. i___________________gallons. WSeptic Tank—Liquid capacity, ��` __gallons Length________________ Width._..__._._._.___ Diameter._...____._____. Depth_____________ . x Disposal Trench—No_ ____________________ Width_______._._.._._._.. Total Length_.____._..______..__ Total leaching area_._._________�,__.sq. ft. Seepage Pit No..................... Diameter.....................*Deepth below inlet___ ............. Total leaching.area..................sq. ft;- , Other Distribution box ( ) Dosing tank Percolation Test Results Performed by____________ ______________________ ____________________________________ Date..._...._.._.....--_'c................. :- . , a Test Pit No. 1________________minutes per inch Depth of Testk Pit.__._`..__._______.. Depth to ground water......... •. .-•- e - - -- Depth to ground water_------_------•"-- ---- ..-- � Test Pit No. 2----------------minutes per inch -----Depth o est= it.....................____.............."_l..^..^�........................................................ °. Descriptionof Soil.................................................................... ------- ---------------------- adyfi W .............................................. -•--------••-----------------------•--------------.......•_ --- --:-- -•-•------- ---•-- ----____-_---------- rxj Nature of_Repairs or Alterations—Answer_when applicable t_ _e -.....__�_.�l!'!u�.___:_ `�--_� ..`....'_�_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with -the provisions of TULE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 9 ued by the ard�fo `health. gate 1 /r . :. ApplicationApproved BY....................................' :__........................................! :........ ---- ....... ' ate Application Disapproved for the follow' ing reasons:........................................=----------•---•--w--............................................... _ ---------------------•---------------------•----------•-----------------------•-----------------•--------•--•-•------------•--•••------------------------•---------•---••--=----•-•---•••-•---••-------- ,, .Date Permit No..... .., _.•----'" • - Issued--•---------------------------•-------•----•-----•_._.. Date ls,! THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " .... 'rj............OF...... .................................. . C�rr�ifirtt�r of �unt�i �nrr THIS�S TO CERTIFY, Tiat the Individual Sewage Disposal System constructed ) or.Repaired ( ) by ` '�" ----------- .....................•------•---------._.._.........-•-•---•---•----•-•----------------- f` In,ller at...... f.1 .f-- -`}/ -------e... ........................... -•-•"------39-- ..---------•----------------------------••---•--.._........-------------- has been installed in accordance with the provisions of TIT -Ee 5 of The State Sanitary Code as described/in/Ithe application for Disposal Works Construction Permit No.. _ -2 --------- dated----------. ....................................' . `1 f THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ 7 Ajf�GDATE__...__........... -- ----------------••--•••••--•-••------••_---• Inspector................ ..........................................=......................... THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH C_ <.-,x oi"X Z ...........................................OF.........................................:........................................... �.�" O . '0 0-. 2. ,,.FEE........................ Etfipuutt1 urkuunurnr# rrnti �� w Permission i hereby granted__.__.�t�'�:�_r_�"'�: ``�r to Construct (4 or Repair an Individual Sewage Disrrosal System �. �r- t. ' - Street as shown on the application for Disposal `Forks Construction Permit„No�-_�___.��_ Dated___.__f___ ......----------------------------------------------------- r � Board of Health _ DATE.... ---`-...-......... --_=----•--............................ FORM 1255- HOBBS & WARREN, INC., PUBLISHERS j ___. .....r�_ �. _ .., ..s.-. � .. ... •.yrt+.Bwr��9fa.c er. � .7.3...6 Eu izbd -(. . FL:ov ]:. SEPTIC TACVK 330 X t .67. • I //c J ,,.c AXLy- F� okl 330 GP, �•T OF M q .:. �R• o L! N Ry�T+E . u yr uF���;� ��'�P Ste^ PETER MCHARD q -SULLIVAN it L BAYTER —:NO. No. 23)33' v 2�040 U T 1 iJt.. ISTrr-1 •'TE.sr'f/a!-.� � t �- 1`�OV.E � 'lZ:l=''/�L,q G� G _ SY47I✓'1''1 fl. `s.�'9��� •�.'� 7"U�'F.s�o=/oU:J e _5 4WD O/ST, Gg L' _ / Box 7.3 �I 7, w�rH 1. W45HC-D • :.. S4.h1D.. rt ST�J:E ,o (�L9v,o � s 8 �S PRo F1 L 27 �s Tf�,47777yE "Dw,CZC.� 1(r S.yaw.v. LCC 30. 7S/ YE��av Gc:VM�GY.S GrW/771 /'vC ,eEGiXI2F ?4 44A 0.SU,evEya,Ps ToW.v aF/,�2�v S�gGt. .G.va /S Nar- A/,aA /ysre— ' shy K/N f�E,2E4 a S?�11�L/Sy ,Coy^• G/NF.,s' . I ,Z Lod- 3S3 PLArJ l T-1nIG 3S;IL � p LoT- 20,9�°'�� 7,1 CA f Xoo. I ,y i I N i A 66 � I IGO. �JRCA►a�` 1c�,G0 J kjo e L, t I Lo-r 3S8 i '�„A-c�►.�T) � ,`` I-k���5e� `lam L T. Tr) _ o i 0 OF PETER j ado SULLIVAN U No. 29733 0 v Lo i C� qG PA 6 4f1 �®a 1 I LOCATION SEWAGE PERMIT NO. VILLAGE ��l�Si�ti� i(Vt IBIS Q2bY� I N S T A LLER'S NAME A, ADDRESS a2P, err®kb 051-MQJsLM- lA1i ST I �_L A =i-- 0ST/Tevrux, R UILD R OR OWN ER DATE PERMIT ISSUED � )GlSG DAT E COMPLIANCE ISSUED a� � J6 P. 1 * COMMUNICATION RESULT REPORT ( NOV. 2.2005 3:18PM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 384 MEMORY TX 915087751117 OK P. 5/5 ---------------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION LOCATION SEWAGE PERMIT No. R VILLAGE I N 5 T A LkER'S NAME A ADQRE5S S AA �J'� �5�'1�►ZVl�L�, R UILa OR OAR ' PATE PERMIT I55UEQ OAT COMPLIANCE ISSUED No..t Fic 6 64 THE COMMONWEALTH OF MASSACHUSETTS '.. BOARD OF HEALTH OF.......................................................................................... Appliratinn for Uiipusal Works Tonstrurtiun Frruti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_..... ........ :..................... ...................................: :..........___.....................__________-_.-•- tlon-..I/ ress n o Lot . ud i .......... . ..-••........................ ......... ..... .........._.............. O n r Address ... CCU'-dl:.. Installer Address P�1 d Type of Building Size Lot ____._6 0t .Sq. feet � Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building L.VQW.�.. trNo. of persons _____________ Showers ( ) — Cafeteria ( ) • P f aYP g •-- --... ---- -- P -- a Ot ures . ... d - --•----------------•-•-------•----- •-_-�-- W Design Flow._..... .......gallons per person per day. Total daily flow_.___ _ ___________________gallons. WSeptic Tank—Liquid mpacity/�? gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed.by-•---•--•••-•----•••-•-••----••---------------------•-••....___-•------•- Date........... ..._------------------------ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P.' ----•-------•------•------•------•--------•----•---------------•-•-------------•----- ------- •--- -------------- •------- •---------------------------------- Descriptionof Soil......................................................................................................................................................................... V _._...••-----_--••------•..............................•..._._..----•........_................................-t� W •-•-----•-•-----•••----------•------•--•--•-•--•-••-------------------------------------•---------•-•-••-Pu'� --------------•------------------------- •-----------___-••-•••-•••••-----____ x 1_.�_Ns: -.__..�Y�Y�Via. U Nature of Repairs or Alterations—Answer when applicable • ] ��- '" �r ' �L... �c�' `-......��?►..t6a ------..d ou ...„� f ir..rv�••�.'T _.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordancewitl the provisions of TITU" 5 of the State Sanitary Code— The undersigned further agrees not to place the system:_iti operation until a Certificate of Compliance has been ued by-the ealth. ned..... ....... -•- • .............................................. -_7 •_... ••• ------- Application` Approved By..... - •----- - • ••--------------•---•--••--• -- --------� ate Application Disapproved for the following reasons__________________________________________ .................................•-----...._...........-•----....-----••--•------------.._............•--.---------•---••••••-•-•••••--------•--••_••-•-=-----,•-••••--••--•---••--•---••-----•---••••- ^ Date Permit . ..- - =- ._-_•-- Issued........... _---------------------------------------- No Date THE COMMONWEALTH OF MASSACHUSEI•TS BOARD OF HEALTH ..........................................0 F...... ............... Trrfif rab of fauntpl�anrr THIS S TO CERTIFY, T at thp ndividual Sewage Disposal System constructed ), or.Repaired ( ) by-------••--._.T.._j.t.l W t - e rater . In ler . at...... .A_ ----------•-•---- 0 - ...�__T.............. has been installed in accordance with the provisions of TILE 5 of The State Sanitary Codq as describ d;in;the application for Disposal Works Construction Permit No..�'__ y__________ _________________ dated__:..___. f----------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .1.-- Aj Inspector THE COMMONWEALTH. OF MASSACHUSETTS ' '^ L e:' BOARD OF HEALTHY .................OF....._.__... ........................................... G7 .�..�... No.. {......... .FEE ........... urk�,/��nn��rnr�iu l+l r Y�i fir' " --•--•-•................. ._.. Permission i� hereby granted: kr ,.:_... ....... to Construct (t/) or Repair ( () al Individual Sewage Dis0sa.l ystem atNo.----. ....... -------- -•--•-•-------••••-•••••--••••-•----•-•-••-•--•-•- ••-•--• ................. Street ,r as shown on the application for Disposal Works Construction Permit; _(a." .2_ _ Dated._.__/_ _.r.. ... . ........:. , a __...a. . Board of Health , DATE:. ....................................... FORM 1255' HOBBS & WARREN, INC., PUBLISHERS A C�3- -5- ✓ LOCATION 2 SEWAGE PERMIT NO. i 3 56 N I LL- VILLAGE (n6tS OMS tM ILLS 02tayff INSTA LLER'S NAME i ADDRESS �iclr-1 zT\ IF1=orb ©ST(T2VILLc,. iu`ST ��aa►,�s��+6�r� QSl 1�2VI�LP� III UI�LDER OR OWNER D A T E PERMIT ISSUED I )G/SG DATE COMPLIANCE ISSUED JI'-7,J&6 �,u at RC-j Ndus� el- 0 ia' r TOWN OF BARNSTABLE 4LOCATION M.\� ?cn SEWAGE# VILLAGE S ti, ASSESSOR'S MAP&PARCEL� (C!3 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY tocw S�c, , LEACHING FACILITY:(type) e7 - (size) (4 ; NO.OF BEDROOMS OWNER ` S t-Ac2t-t)9--rma,-- PERMIT DATE: COMPLIANCE DATE: '� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) M I A= Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi acility) /J Pr rFeet FURNISHED BY G'Yhte.rl ® c 1 Da No.: .....s.. / Fiza. � THE COMMONWEALTH OFMASS;CHUSETTS G /�h L A R D O F E A 1 _r Lj o............. .. .. .. ...... . .. .......... y Apptiration -for 4%ipoott1 Workii Cnomitrurtion Prrutit VApplication is hereby made for a Permit to Construct (v )-or Repair ( ) an Individual Sewage Disposal Syst at �..:.. .... ...... .....el: .... .. .......... Loca Address t o O Ad wnerL/l�Arizddress --- Installer Address 1� ,(/ U Type of Buildings Size Lot...7._ -$ ---- -- -Sq. feet Dwelling No. of Bedrooms______________�-_.----_-----------_-.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------- ---------------------- -- w Design Flow-- --------------------- tllocys per person per day. Total daily flow. gallons. ---------- -------- WSeptic Tank;t-Liquid capacitiV4 _._gallons Length-------------_ Width................ Diameter---------------- Depth-__.__----.--.- x Disposal Trench—No..................... NN[Id li____.......____.�tow gth__ . Total leaching area.._.___._...._.__._.sq. ft. Seepage Pit No.._ __�____ Diameter_ --- Din et................'__ Total leaching area_-_-.-_.-_.-___--sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water__..__--_---_.--..---_ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water aw < _ . L. .. water--.-.-.----.--------.._. _____ ___________ ....... ----_. � Description oo ________ U -------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued b the boar of health. Sign ... .. ... . --•..�---05 --- --- ----------------------------------- Da Application Approved By.-- / /'{L3 � Date '-•- Application Disapproved for the following reasons:.............. -------------------------------------------------- ..-----••---•----•--------•------•-•-•-•------------•------------•--•---••-----------------------•----••----•-•--......•--••--------------------------------------------------------------------------- _ / Date Permit No.------......................................................... Issued Issued---•••--•-- ............. Date 4 Fsa No...... .................. THE COMMONWEALTH OF MASSACHUSETTS •BOARD OF HEALTH, _. ... 6 Pam✓' ......_OF......'1���� Appliratiutt -fur Uiipuiitt1 Morkii Towitrurtintt Pp// mit Application is hereby made for a Permit to Construct ( ' ) or Repair ( ) an Individual Sewage Disposal Syst at: p = 7 �- � r.�r .q Locatiio -AddressrlY& b o o d... ------✓a — '�r''t�� ..... --�------,�-- �.y^3,r'-"rt�'ilr'_"f--•---•--------••--••- --�---P"--'''---`---- �'�-J-t-•-- _��'2-"-- j - Owner Address W Installer Address Q Type of Building,, Size Lot............................Sq. feet U Dwelling-No. of Bedrooms............... ............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons.--_•--•____________________ Showers — Cafeteria QI Other fixtures ------------------------------------------------------ W Design Flow__________________________, �- ..__ �111� per person per day. Total daily flow............. ....---gallons. Septic Tank Liquid capacity j _..gallons Length---------------- Width------.......... Diameter------- Depth................ xDisposal Trench—No- -------------------- Width----------- otal 1--Z....../_.. Total leaching area--------------------sq. ft. Seepage Pit No.__� ... .__.. Diameter �� .._ Depth blow inlet.................... Total leaching area.................. it. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date--------------------------- ------------ ,� Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ Gz., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth , t :to -ground water__..----____--__.-__----. -0 ou---- UW T ••Description of Soil----- ----------- ' � ------/77 .. l---------------•-----------••------ ---- -•--•---------------- ---------------------------------•---------------------------•------- --.------------•-------------------..------------------------_.--_-_----.--------------- --------------------------------------- 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 issued by l the board of health. Sign ' ' ..........11. � ........................................................ Da e Application Approved BY---- ' ; ..._ .._.._ �_ . . " .,` ..... Date Application Disapproved for the following reasons:...........................l /............................................................................. ---------•---•-----------------------------------•----------•-----_--------•---•-------•••----------------------•-••----•------•--•-•-------------------------------------------------.--------•--.---•- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF......le?.e;M .: ..................:.......a.......... 10.1rrtifirtttr of Tilut rlitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �_<orRepaired ( ) y.._. .......................................................... ________________ _ .A ^N ( Installer t ew -- . Y has been installed in accordance with the provisions of Article XI of TheState Sanitary de d scri Id inxthe application for Disposal Works Construction.Permit No.............. iff�.2�_-•____-__- dated.. . . THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O / HEALTH . 0 No -- ••--•- FEE: .................. Di spatial grk (n�t� trurtil�tt rrmit Permission is,,hereby / ; granted.............__.__.._ stem j raj to Cons dV o R an`Indi�al/S agg Disosal,.Sy atNo.. -_..._` _ .� - ........................ street . .� as shown on the application for Disposal Works Construction Per 'it°'No.._ :, ______ Dated-----{�-'` -/......... DATE ---------------------------------------------• Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �� �Y !: v^v+,��,« '�.*�.,,,.,.,,,,�:*^v«,.+..•,...,w,*r ,...� vrev++.-r,..+. �+.p,.+,„..;„"x.,,M_„d,.,.. '-s,,,•�,,,� i... ; ' t I M N m IN AA rN mC � 19 J All /JO v ' 0 _ R 5.4'ed3 4nd i V.� 1d'ic c-Hdci: .� � � 3 6f tha Ttwn Clem �SCFZ / �� moob' /�✓ /� �'� <c:ya/s��� T�9<-/T_� I '. �`o• `gyp\r.'�`'t r�/�\5�-/'�" �� � 'v f ' mi"N""'F'w `T^st -"`IT ',k'F..,vr b.h -•+" , F _. , - -�'a