HomeMy WebLinkAbout0073 MILLRACE ROAD - Health i MILLRACE i6I MARST. MILLS47.
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M TOWN OF BARNSTABLE
LOCATION '13 SEWAGE#
VILLAGE \ASSESSOR'S MAP&PARCEL 7
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'S NAME&PHONE NO.';R
SEPTIC TANK CAPACITY 1CDQ)Z
LEACHING FACILITY:(type) (,.�..,�.1.� p`;�i' (size) C r K
NO.OF BEDROOMS
OWNER Co C, -\,
PERMIT DATE: COMPLIANCE DATE: kO
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form copy
Subsurface Sewage Disposal System Form- Not for Voluntary Asses is
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is Marstons Mills MA 02648 April 3, 2015
- required for every _p
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information 3
�,.
on the computer, I
use only the tab 1. Inspector:
key to move your
cursor-do not Patrick T. Sullivan
use the return Name of Inspector
key.
Ready Rooter Excavating
,L Company Name
P.O. Box 89
Company Address
Forestdale _ MA 02644
City/Town State Zip Code
508-888-6055 S112843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
April 10, 2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owners Name
information is required for every Marstons Mills MA 02648 April 3, 2015
_
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 f the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" ( , N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years of or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration ore filtration or tank failure is imminent. System will pass
inspection if the existing tank is replaced th a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspec on if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tan s less than 20 years old is available.
❑ Y ❑ N D(Explain below):
t5ins•3/13 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is Marstons Mills MA 02648 April 3, 2015
required for every _- p
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 ealth):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain.below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is level d 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 he Board of Health:
❑ Conditions exist which require fu er evaluation by the Board of Health in order to determine if
the system is failing to protect p lic health, safety or the environment.
1. System will pass unless oard of Health determines in accordance with 310 CMR
15.303(1)(b)that the syste is not functioning in a manner which will protect public health,
safety and the environm t:
❑ Cesspool or priv 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
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 3, 2015
required for every _ P
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 SqS is within 50 feet of a private water
supply well. (/
❑ The system has a septic tank and SAS and the SA 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 analysi , performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the pr sence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no oth 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 1/z day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is Marstons Mills MA 02648 Aril 3, 2015
required for every p
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ ® 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 sy/amapped
within 400 eet of a surface drinking water supply
❑ ❑ the swithin 00 feet of a tributary to a surface drinking water supply
❑ ❑ the sloc ted in a nitrogen sensitive area (Interim Wellhead Protection
Area ) a mapped Zone II of a public water supply well
If you have answered"yes" uestion in Section E the system is considered a significant threat,
or answered "yes" in Sectiove the large system has failed. The owner or operator of any large
system considered a signifiat under Section E or failed under Section D shall upgrade the
system in accordance with R 15.304. The system owner should contact the appropriate
regional office of the Depar
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 73 Millrace Road
Property Address
Gerald McCourt, C/o.- Patricia Batchelder
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 April 3, 2015
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ - Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)(310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD
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
73 Millrace Road _
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is required for every Marstons Mills MA 02648 April 3, 2015
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
0
Number of current residents:
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 2013=89 GPD
g ( y g (gp )) 2014=65 GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy., January 2014
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., c.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank prese ? ❑ Yes ❑ No
Non-sanitary waste discharged the Title 5 system? ❑ Yes ❑ No
Water meter readings, if ava'able:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
i
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
i
73 Millrace Road _
Property Address --
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 April 3, 2015
page. Cltylrown 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: Owners records
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Site tube on truck
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 - Title 5 Official Inspection Forth: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
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 April 3, 2015 _
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System installed 10/22/1987. Certificate of Compliance on file at Health Dept.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: n/a
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1 4
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.6'X 4.5'X 5' 1000 gallons
Sludge depth: 5
15ins•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
73 Millrace Road _
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owners Name
information is required for every Marstons Mills MA 02648 April 3, 2015
page. Cityfrown 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 29 —
11
Scum thickness 0 —
Distance from top of scum to top of outlet tee or baffle 10..
Distance from bottom of scum to bottom of outlet tee or baffle 13" _
How were dimensions determined? Tape measure and dip tube. _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet concrete baffles in place. Liquid level at outlet invert. Risers bring covers within 4"of
grade. Tank pumped and cleaned as part of the inspection. Recommend maintenance pumping every
2-3 years. _
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 sc m to top of outlet tee or baffle —
Distance from botto of scum to bottom of outlet tee or baffle —
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
73 Millrace Road
Property Address
Gerald McCourt, C/o.- Patricia Batchelder
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 April 3, 2015
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 farm and float switches, etc.):
7
"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
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder _
Owner Owner's Name
information is required for every Marstons Mills MA 02648 April 3, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
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 located and inspected with camera. One inlet, one outlet. No solids carryover. No sign of
leakage or high water staining over outlet invert.
Pump Chamber(locate on site plan):
Pumps in working order: / ❑ Yes ❑ No"
Alarms in working order: / ❑ Yes ❑ No`
Comments(note condition of pump c mber, 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•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
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is required for every Marstons Mills MA 02648 April 3, 2015
page. City(Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-6'X6'w/stone.
❑ 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.):
Leach pit dry at time of inspection. Very light staining 3' below invert. High water dark staining 1'off
base, 5' below invert. Clean stone visible through side wall. No sign of past hydraulic failure. Riser
brings cover 6" below grade. _
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 infl w ❑ Yes ❑ No
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i -
Commonwealth of Massachusetts
k Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
73 Millrace Road
Property Address
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is
required for every Marstons Mills _ MA 02648 April 3, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
— f
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 73 Millrace Road
Property Address
Owner
Gerald McCourt, C/o: Patricia Batchelder
'
information is Owner s Name
required for every Marstons Mills MA 02648 page. Cityrrown — April 3, 2015
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: '5
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: 1987
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:
maps.massgis.state.ma.us/Oliver ph
You must describe how you established the high ground water elevation:
Test hole in 1987 found no ground water 11' below grade. Base of leach pit 8' below grade.Accessed
local ground water contours and topo mapping. No high ground water in area of system. Slope to
West of property drops well below 5'from base of pit
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sew
age Disposal System Form-Not for Voluntary Assessments
M 73 Millrace Road
Property Address --- — _
Gerald McCourt, C/o: Patricia Batchelder
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 April 3, 2015
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•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
`t7-1 $7
_
No. 96......E Czt_ Fps...:.... ...............
THE COMMONWEALTH OF MASSACHUSETTS /
BOAR® OF HEAL H
-------- J �..:V.1/.... 1OF......)3........... .. .. ..
Appliration for Disposal Works Tons rnrtiun Vrrmit
Application is hereby made for a Permit to Construct (_} or Repair ( ) an Individual Sewage Disposal
System at:
............. . .r _ T�. �-------1.� .... .... ..... i. e, -----6-oop
. Location-Address
W .....................
Owne
ddress
Installer Address
U Type of Building Size Lot_.,:E J'4./.r..Sq. feet
Dwelling—No. of Bedrooms-------- -- -------,..............__....Expansion Attic ( ) (Garbage Grinder ( j
Other—T e of Building -------------- Showers — Cafeteria
a —Type g j?U _ No. of persons
Otherfixtur ._........................................ •------••----------••••••-•--- -------------------------•
DesignFlow
..,�........................gallons per person per/da Total dai fl9, � ns��
WSeptic Tank—Liquid*capacity../ gallons Length.__ ...(j_. Width.. /.._{�_ Diameter_______-----•__- Depth.�1�_-
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....., ,Y._!./Y� /1lr��.l i_6......... Date.............. lG r-
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water___�}-}......___.... _.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water/y__a-. ?
----------------------------------------•--•-----•---•--••-----....._...
.
O Description of Soil......................... - l ��------••-• ................................ ----------..-•----.
x
t., ------
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ued by the boar o ealth.
Signed...... ------ .....
Application Approved By................................. •-- ............ -- . ¢_ .Z,�Date
.g ....
Dat/
Application Disapproved for the following reasons-----------------------------•-------------------------------------------------••--•---•......................--
-••---•--•-•--•------...................................................................................................................................................................................
Date
PermitNo....... 17.-.._ .0...................._.... Issued_.......................................................
Date
r.�r
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I A- F
DATA
No......................... Ficz..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!.
" ..... .......-'..?OF......�.:.....0 ?.... f 7......................
Appliration for Disposal Works Tonstrurtiun ramit
Application is hereby made for a Permit to Construct (--) or Repair ( ) an Individual Sewage Disposal
' "'System at:
•
Location-Address �No.
vW
-... ...... ....... .... .. .......... .x. . ? l r (/-'• .............--
Owner
A�d}dress
PQ
Installer Address ��
UType of Building c y Size Lot..-__.......... ..........Sq. feet
I.a Dwelling—No. of Bedrooms.___.__: .. .......................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _?; lr�!`_�.... ;? No. of persons......................... Showers (�) — Cafeteria ( )
.,
d Other fixtures ---•-----•-------•----•----•-- ----------------------------•-----------------•••------•-----•------
W Design Flow......_....., .................•..gallons per person per'dayi Total daily fl9w.........: .: ._..._.............gpdons//
WSeptic Tank—Liquid capacity.jA f%t3.gallons Length__�._ ___ Width..k... Diameter________________ Depth. . .-.
x Disposal Trench—No. .................... Width..............._._.. Total Length___...._..........._ Total leaching area..... ___......__sq. ft.
___-: Diameter............... .. Depth below inlet.........__ "'
Seepage Pit No..__..._�_..._ ._. p ____._... Total leaching area.__..l_�_;�__sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed
byW ..._ (.-
Date. .. - ...........
Test •-•---
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
ri, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__
O r .�•/-r----�1�.------...-A-. �J�..7.. .......................
_ �
Description of Soil "_ .....:_.. -}s�.._...---•--....
x
W
UNature of Repairs or Alterations—Answer when applicable.....................................................__.._...._.............._......._..._......
---------------------------------•----•------------------------------•--------------------------•------------------------••••----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary.Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of5health.//
Signed ....= ...... = ...................
Date
Application Approved By.................................................... .. ----•---- - '2 by$
Da
Application Disapproved for the following reasons----------------------••---------------------------- ---------------------------•-
........................•--•---------•--•----------...------....---------------------•--•------------•----•---•-•---•--------••-•------•---•-•--•••--------•----•------•--------•-------------•----_....
Date
PermitNo......................................................... Issued-=-==----------- .............................--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTHY
, .
Trr#ifiratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage-Disposal System constructed-(-) or Repaired ( )
b , i� 57.11 . .fJ 1/l J) -f
r- , . .�
7 Installer
/
at. .---...-•-------------------,-•------•--•---------•----•------------•-•--•----••--•---•-----•-•••------•-----......-•-----••---.
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application,ifor Disposal Works Construction Permit No......................................... dated-.----------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................. ® ��-'1-.r.. .................................. Inspector..................... ...........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... , a rv'1 OF 1 l ?fit' `.._f t '('
,6 ,......,.............................:.
0.......... •.. _ FEE,.5d..............
Disposal Works TAan#rwtion Prrutit
G _/
Permission is hereby, granted. ----_- -- --•- ------------- ,_..y r l
-to Construct (-�) or Repair ( : ) an Individual Sewage Disposal System
atNo...................................... • --.--- -• ................... MCI
-------•------- --- CI 13, ...................................
Street
as shown on the application for Disposal Works Construction Permit No .._........... Dated....... •-3�_. �.•-•-
-----------------•--------------•-•-------- ..g =
DATE:. 7 Boa;of it
- ----•---- --------- -------------------- , �J
FORM 1255 A. M. SULK I INC., BOSTON
�\ /
73 Irl•��,i�ic.� 1
T W OF BAR LE
LOCATION SEWAGE # kw
(ILLLAGE 4�eOVJ / ASSESSOR'S MA & LO 7 7
INSTALLER'S:NAME & PHONE NO.
� �� S.
��`SEPTIC TANK CAPACITY
""LEACHING FACILITY:(typ ) / (slze
"0. OF BEDROOMS 3 PRIVATE WELL PUBLIC WATER
BUILDER OR OWNER " v
IJATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: h �.
VARIANCE GRANTED: Yes No
a 0�
1
N� cm? s:
/W C2
TOWN OF BARNSTABLE
LOCATION Lo 1 Xk�k k SEWAGE #
VILLAGE 1Mvc5,� 5 VA-A` ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. U,l O `YCA ??(- l 0`!0
SEPTIC TANK CAPACITY 1,�600
LEACHING FACILITY:(type) � 01) A, 4ofOCS (size) 17 X 3Z 3
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER �41�JS �c�e ;ut0i 6Ui 27L019�/
{
DATE PERMIT ISSUED: qq
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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