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Home My WebLink About0143 MISTIC DRIVE - Health 143 Mistic Drive Marstons Mills P Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 10/19/2010 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furt r Evaluation by the Local Approving Authority 10/19/10 Insp 's Sig ure 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•09108 Title 5 Official Inspection Form:Subsurface Sewage D posal Syste age 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): 1 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No Backup of sewage into facility or stem component due to overloaded or ❑ ® P 9 Y Y P clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09108 Tide 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 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. •09/08 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Lt5l"s 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 10/19/2010 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ® ❑ available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® El 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): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 143-Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 10/19/2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 117 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5•''L 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: e0+ t Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 4" 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 11" 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.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts to Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level.box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps In working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 17 I • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �w 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Sandy soil.No signs of hydraulic failure.Pit#1 was dry.Satin line 48" below invert.Pit#2 was dry.Stain line 30" below invert. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: , Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 10/19/2010 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: PA r F r t fyp•¢'"f�1,t'„¢ �10 ..d wr .�5'• 'y� y '; j 9. ry O �6 O Set Scale 1" = zo I Aerial Photos t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 40' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 10/19/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 J , ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands 0 �P Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises LLC Company Name r� P.O.Box 763 Company Address ( _ Centerville Ma. 02632 r City/Town State =7,ip Code (508)428-4028 S14454 Telephone Number License Number {, r 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 3/10/2008 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. 143 Mistic Dr.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 143 Mistic Dr.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every page. City/Town 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. 143 Mistic Dr.-12/07 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 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills required for Ma. 02648 3/10/2008 every page. City/Town State Zip Code Date of Inspection B. Certification cont. C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. M Method used to determine distance: e **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 El ® 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 ❑ ® 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. 143 Mistic Dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every 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 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 143 Mistic Dr.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 3/10/2008 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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 ® El 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. El ® 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)] 143 Mistic Dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 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 ears usage d 2006:156,000 g ( y g (gpd)): 2007:208,000 Sump pump? ❑ Yes ❑ No Last date of occupancy: 3/10/2008 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): 143 Mistic Dr.•12/07 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 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No 143 Mistic Dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 ' Commonwealth of Massachusetts W. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 3/10/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 2.5' p g feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No .-------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gallon Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle29 Scum thickness 3" . 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 12" How were dimensions determined? Measured 143 Mislic Dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): 143 Mistic Dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 3/10/2008 required for every 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has 2 outlet laterals with equal distribution.No evidence of solids.carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 143 Mistic Dr.-12/07 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 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is Marstons Mills Ma. 02648 3/10/2008 required for every 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: 2-100.0 gallon ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Pit#1 had 6" of water and stain line 48" below invert.Pit #2 had 2.5'water with stain line 30" below invert. 143 Mistic Dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 ' Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every 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.): 143 Mistic Dr.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 MAP Page 1 of 2 Town of Barnstable Geographic Information System y Parcel Viewer I Custom Map Abutters Map Size ® ® Zoom Outj I jl M j fl M f jIn y r 2 r j t i r� r + i + + ( - _ r L.r r' r t �r � , r r. . i _ 1.f Set Scale 1" = 20 I Aerial Photos r-n—inht 9MF_9l1f17 T—in of Ror—tnhln iiAA All rinhtc r.—I, lhttr.'/A:mmir fmim liarnetQW.-ma nc/arr imc/anr�aPnar�rt/man aer►v�r�rnr►arfi>TTl=n7Un5nR�mar� /i /�nnR Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 143 Mistic Drive Property Address George Rowlands Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/10/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells depth to high round water: Bottom of LPs 40' Estimated de p g g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 Plate#2 annual ranges of groundwater elevations. 143 Mistic Dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 r - Town of Barnstable y�P ti� Regulatory Services Thomas F. Geiler,Director 19. Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 . This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of be approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. A DATE_s_48•4aA-•--_- PROPERTY A� Marstons Mills RECEIVED --MA 0 2 6 4 8 _________ On the above date, the me -septic system at the above dt"61*"04 TOVVH OF gH DEPT BLE Inspected. o This system cnsists of the following: 1: 1-15,00gaiion 3e/2t cc tank. 2. 1-diht2 cQ��o�n Beaching ��th. 3,•2_10 0 0 g: Based on inspection, I certify the following conditions: tic hyhtem (78' code). t.ic, h yhtem ,l-h in �?o�/ze2 wo2k�.ng 0ade/G 5.,The h e.P at the paehent time. SIGNATURE: -Ro -- - Name:_ bert_Paoln- ___--- Joseph P_- - Macnber Company: Qn, Inc. Box 66_---------- Address---P--- 9 Centerville MA 02632�066 ,RCE.L nT ( ) 775-3338 - ' Phone---- 5-0 8 _ ----- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY SEPW P. MACOMBER & SON, INC. JO Tanks--Cesspoots-Leachfields Pumped & Insta�lect. Town Sewer Connections P.O. Box 66 Centerville, MA 02632'0066 / 775.3338 775.6412 I Cx COMMONWEALTH OF mASSACHusE`J'TS EXECUTIVE OPPICK OF EI�R4'NM'WN'TAL AFFAIRS DEPAUTMEN OF +'NV1 4I� N'� �R�T CTION OFFICIAL INSPECTION FORM_.NQT FOR V_OLVNTAcR'Y ASSESSMENTS SURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIMCATIQN• Property Address:' 1 4 3 M j i r- Dr i vP h"gr�tnn Nf9 1 1 c� ►vI4 •02648 Owner's Name: Jon n, Owner's Address: caMn Date of Inspection: Nance of Inspector: (please print)R h,�a IBC,,- Company Name; P .Pol '1 Mailing•AddWess: Cen e zb7 e. .ab ,•02632 Telephone Number: 5 0.8:.77, -j 3 CERTIFICATION STATEMENT he certify that I have personally inspected the sewage disposal system.at this address and th erfortti' based on my�d 1 fy ection.The inspection was p below is true;accurate and complete as of the time of the insp �P training and experience in the proper function and maintenance of on•gite sewage disposal systems.I am a DEP approved system inspector pursuant fo�8t.ction.P5:340.of•T,it1e'5(31'0 C'MR,;'S:•000). The system: XX Passes -Conditionally Passes Needs Further Evaluation by the Local ApprovingAu h rity ails ' Date:• • Inspector's Signgfu"re: The system inspector shall submit a copy of this insp ection re'61i-to the.Appl;oVin&Authority(Boud of Health or ow Of 00 0 DEP)within 30 days of completing this inspection.I1u T submit t the `he*report to the appro a regiona�offiee of the gpd or greater,the inspector and the system'owner.s the buyer,if apphcable and the approving. DEP.The original should be sent to-the systetn•owner and copies sent to authority. • , r fir�" �' .�;'.'. W Notes and Comments x **** report only describes conditions at the time of inspectloirand under the conditions ame a different 'phis rep y time.This inspection does not address.how the system will perform in the future under conditions of use. Page 2 of 11 OFFICIAL INSPECTION,FORM—NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM.INSPECTION FORM PART�A CERTIFICATION (continued) Property Address: 143 Mi s t i c Dr. MarGi-nn Mi l l c 0 MA Owner: Tna n n P T.nva 1 lz Date of Inspection: g f Q/n d Inspection Stinrmary: Check A,;B C,D or..E-/AL_WAY$`comglete�all of SectionO A. System Passes: n o 1 have not found any information which indi'bates-that any of the failure criteria described:in 310 CMR 15.303.or in 310 CMR 13.304 exLst.Any failure criteria not evaluated are indicated below. Comments: _ Septic zyZ.tem iz in p4ope2 woak.ing o/cde/t a� . the p zeze.¢nt time.- B. System Conditionally Passes: n o One or more system components-as described in the"Conditional Pass"section.need to be replaced:or repaired.The system,upon completion of-the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in-the for the following statements.If"not determined"please explain. R-o• The septic tank is metal and over-20 years old*or the septic-tank(w:hether metal.or not)is:structumlly unsound,exhibits substantial.infiltration or exfiltration.or tank failure.is:irr minent: System will pass inspection if the existing tank is replaced with'a complying septic Vmk.as$,ppmved 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 o 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 distr'ibiltion box is leveled or replaced ND explain: h o 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): 1.. broken pipes)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM NOT VOR VADLUNTARY ASSESSMENTS SUBgtWACE S W.A.�CE DISFOS*L SYSTEM INSPtCTION.FORM PART:A 'CERT-MCAMON'(eontinued) : Property Address: 1 4 3 M j a t;J e ,8�p Owner:.•Date of of Inspection: a4 C. Further Evaluation-is Required by the Board of Health: n Conditions.exist which require further.evaluatio4by.the.Boar&ofHeaith:in order.:toActertnine ifthesystem is failing to protect public•health, safety or the environment. 1. System will pass unless Board if Health determineskin atcordaince with 310.CMR 15:303(l)(b)that the system is-not funtctioning in.a•manner which-will.protect public health,safety and•tbe•.environment: naCesspool or privy is withim50 feet of asurface water Cesspool or privy is within 50 feet of-a bordering vegetated wetland or a salt marsh. 2. System Will'fall unless the Board-of Health{and Public Water Supplier0f any)determines4hat the system is functioning in a manner that protects the pablic health,safety and environment: no The system has a septic tank and soil absorption system•(SA•S)-end the SAS is within 100 feet.of a surface water supply or-tributary to a.surface water-supply. n o The system-has•a.septic tank and SAS and the!SAS is within a Zone 1 of a-.public watensupply. no The system has aseptic tank and.SAS'and-the-SAS is within,50 feet of a private water.supply well. no The system has a septic tank and SAS and the?SAS is less than 100 feet.but 50 feet or.itiore frog a private water supply well**. Method used to determine distance- "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.'A copy of the analysis must be attached to-this form. 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SURSURFACE SEWAGE.DISPO&AE SYSTEM.INSPECTIWFORM PART A CERTIFICATION(continued) Property Address: 143 Mi s t i c Dr. Marston Mills; MA Owner: Joanne Lovely ' Date of Inspection: 9/8"/ 4" D. System Failure Criteria applicable to all systems: You must.indicate"yes"or"no"to.each of the:followitig,for,all inspections: Yes. No x Backup.of sewage-:ii tb facility.or.:systern component.,due to overloaded:or clogged SA-S.or.cesspool Discharge:or*ponding of effluent to the surface 0the::graund 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 hiquid depth in-cesspool is less thank"below invert or available volume is less than'h•.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 x Any portion of SAS;cesspool or privy is below high ground water elevation. _ x Ariy.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 privyis within•a1-onel 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 watenanalysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution;from:that.facflity and:the presence-of aritmonia 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.] 'L O (Yes/No)The system fails. I have determined that-one or..more-of the:4bove.failure::criteria exist as described in 310 CMR 15.303,therefore-the system-.-fails..The system ownenshould 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:systtni must.serve..a facility with a design flow of 10100.0 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((nterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you haveanswered"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 OFFICLAL INSPECTION TORM-NOT FOR VOLUNTARY ASSESSMENTS r $ttSSURFACE-SEWAGE DISPOSAL`SYSTEM IN-SPECT14ON FORM PART B CHECKLIST Property Address: 1 4 3- Mi s ti c Dr— . Marston MT11s nrt,P, Owner:. Joanne L y-pl y Date of Inspection: ".A 9 18 n A Check-if the following have been done You must indicate"Yee or"no"as>to each.of the following: Yes No x _ Pumping information was prpvided-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 '-inspection? x Were as built plans of the system'obtained and examined?(If they were not available�bote is 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? Were all system components,excluding the SAS,located on site'? _ Were.the septic tank manholes uncovered;�psned,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 diff6rent 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 detenn ned based on: . Yes no . . oard of Health. x Existing information:For example,a plan at the B " _ 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)] Page 6 of 11 OFFI-IAL WSPECTI:ON]FORK-NOT FOR�V..4LIFNTARY ASSESSMNT,S .SL BS PACE-SEWAGE BIS'P,OSAL iSYSTUM,%INSPEMOT9:FORM PART.0 -SYSTEM INFORMATION Property Address: 143 M;-Gt; c- nP _ Marston Mi11c� MA Owner: Toa Date of Inspection: �9,18 44 4 FLOW CONDITIONS RESIDENTIAL 4, Number of bedroAms(design):.,,, _, Number ofbedrooms(.actual): DESIGN%flow based on•310 CIG11� 15.203':(for eY&41e:•I IO gpd 0-6fbedroo1iis): 4.x-110=4 4 0 y12d Number of current residents: .: 2 I.oes.residence have a garbage grinder(yes or no): no Is laundry on a separate sewagAystem•(yes or.no):.p (if yes separate iaspgFti9n eq. uired] Laundry system inspected(yes or no):�z SeAsonal use:(yes or no): . n o co �33;O� j Water meter readings,if available(last 2 years usage Sump pum (yes or no): n o J Last date o�occupancy: ;A e.6 e n z` COMMERC)fATJSTRIAL Type of estate .. .peat: na. Design flow...( on 310 CMR 15.203):• I na d Basis.of aSigli' low(seats/persons/sgft,etc.):, na Grease trappresent(yes or no):h Industrial waste holding tank present.(yes or no):na Non-sanitary waste discharged to the Title 5 system•(yes or no):na Water•.meter readings, if available: na Last date of occupancy/use: . na OtgER(describe):. na GENERAL INFORMATION Pumping Records Source of information: �,'P.'flacomgen and .son Was system pumped as part of the inspection(yes or no): Ua.6 If yes,volume pumped: 15 0 0 gallons--How was quantity pumped determined? m e a z ult ed Reason for.p..umping: m ez m i n i n."o TYPE OF SYMEM , a Septic tank,distribution box,soil absorption system _Single.cesspool —Overflow cesspool —privy _Shared system.(yes or no)(if yes,attach preyidus inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system —Tight tank _Attach a.copy•of the DEP.approval -Other(doscribe): Approximate age of all components,date installed(if known)and.source of information: 1990 Were sewage odors detected when arriving at the site(yes or no): 6 - Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 1 m; Wi t; ,. nr. Owner:T„=„„e MA Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 160 Materials of construction:_cast iron x 40 PVC_other(explain): Distance from private water supplyvell or suction line: 0 t Comments(on condition'of joints,venting,evidence of leakage,etc.): o.ini�s a e¢2 t.i ht. No evidence o 7eaka e. S atem .its vent ZnAough .the house yenta. SEPTIC TANK: (locate on site plan) Depth below grade: 20" Material of construction: x concrete;_metal fiberglass_polyethylene --other(explain) If tank is•metal.list age: n o Is age confirmed by a Certificate of Compliance(yes;or no):—(attach a copy py of Dunensions:5 ' 8"w.ide, 5' 8"k.igh 70' 6".gong Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness: 1' --- Distance from top of scum to top of outlet tee or baffle: 6" 1 ) C1 I Distance from bottom of scum to laottom of outlet tee or baffle: 8" How were dimensions determined: m e a s u t e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural irate liquid as related to outlet invert,evidence of leakage,etc.): ldty, q d levels tank. ap .ea2a atauc-tu,cai—,1 aound.•No evideaee o 2eak¢ge, in et ¢nd out Qet .tees ate .in Pace. GREASE WRAP:n°O(locate on site.plan) Depth below gradena Material of construction: concrete_metal— fiberglass (explain): rz1 _polyethylene—other Dimensions: R Scum thickness: n a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or-baffle: na Date of last pumping: na Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte as related to outlet invert,evidence of leakage,etc.): grity,liquid levels ,7 tea not ne�sent. Title C TncncMinn T:nrm Kra;/innn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '90,89URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 4'1 Mi --i:iC L1r, P413 :19 MA Owne • gaRpe r r: Date of Ibspectlon: ws TIGHT or HOLDING TANK:no (tank must be pumped at time of inspection)(locate on site plan) Depth below.grade: na Material of construction: na concrete metal fiberglass_,_polyethylene other(explain): Dimensions: na Capacity: na gallons Design Flow: na gallons/day Alarm present(yes or no): na Alarm level: na Alarm'in working.order(yes or no): na Date of last pumping: na Comments(condition of ai.arm and float.switches,etc.): tight oa ho.ed.ing tank.3 not Raezent.- DISTRIBUTION BOX:6teh (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): _/7 Pnx iA Poug P No ouid ance n4 e'p,rhino •info nn niif n Pnr_ ^�/n o�)idonro n4 .en 4 rla BOX ha.6 LWO .eate2a.e4. PUMP CHAMBER:no (locate on sife.plan) Pumps in working order(yes or.no): na Alarms in working order(yes or no): na Comments(note condition of pump chamber,condition of pumps and appurtenances,ett;.); Rump chamge2 not i &ezen.t.� 8.� Page 9 of 11 OFFICIAL INSPECTION )FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBgURFACE SEWAGE DISPOSAL SYS'I?EM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 1 4 3 M i -tin n r Marston MTl l ..r MA Owner:. Tnanne r 3.el Date of Inspection: l� SOIL ABSORPTION SYSTEM(SAS):_.(locate on site plan,excavation not'required) If SAS not.located explain why; Type _ye.6leaching pits,number: 2 no leaching chambers,number: n leaching galleries,number: hes number,length: trenches, gt n o leaching , �—leaching fields,number,dimensions: overflow cesspool,number: ovative/alternatives stem Type/name of technology: n n 1tu1 Y Comments(note conditionsigns of soil si of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �. CnJO.1 C]R ona rinii No vuidvn y o hucl2 aieuae CESSPOOLS: n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: as Depth—top of liquid to inlet invert: na Depth of solids layer: na Depth of scum layer: na_ Dimensions of cesspool: na Materials of construction: na Indication of groundwater.inflow(yes or no): na Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce.6.3 ooez -aZe not zesent. PRIVY: no (locate on site plan) Materials of construction: na Dimensions: na s• na Depth of solids:P etc. Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, ): l Z.iv not 1te,3ent. 9 f Page 10 of 11 OFFICtiAL INSPECTION FORM NOT FOO ?VOL.UNTARY:ASSESSSMENTS / SURAWAOE'SEW— AGEMIScI?.OSA SYSTEM"INSPEGTION:FORM PAR`C' SYSTEM M—ORMATI'ON(continued) Property Addressi: 14 3 PU.6 t.i c DIL•' /7a&,6ton.6 lrl i��s. lrla. Owner: Joanne Lcv Date of Inspection: 9 SKETCH OF SEWAGIE•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 lojfeet.Locate where public water supply enters the building. N I, Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 4 1 M; gf-; C nr mars on Mills, _MA Owner: Joanne r ,.ve y Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 60J. feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: hii-12. , oh.)n 9nRnziafl,.Qe.-ma.-ue You must describe how you established the high ground water elevation: u,,ynd-a rihPAiU and Ni_ZDn_a_ morin_.P_ 12116194 giaound wa.tez a&ove aea level u.eed -7achc:ica ? llugC¢f %n 97_0n0_1 uYnIP42 7azz.- 1992 Annuai /langeh g�aourad �eete� aeauect 6eus� . C9ra V ad High Groundwater Adjustment 1 .8 per Frimpter Method �v Therefore, the vertical separation distance between the bottom of the leaching pit an5 the adjusted ground- water table is ? feet. f e - " Y:r•rrnrrr rn+ra>-'-rr:rRrmr:nr.++iv•r*rrt+rrr.�rrvsnr-Tarrieervs+am*tnrrn�arrasrerrrse 1 TOWN OF WARD. OF 11EALT11 SOBS114FACF SEWAGE VISPOSAG SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ••s:•t-r•:-::,--.ir..•:--nrr.+n•n:rrtrnr.•ersrrrrahr+'rs�rmrt+tressner'�'�*R -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 143 ('7izt is [72. ASSESSORS MAP , B609 K AND PARCEL # 079-050 , OWNER' S NAME aoanne Coveiu PART D - CERTIFICATION NAME OF INSPECTOR !Rn o-2L 20e g-a,t._ - - ., . COMPANY NAME a•'l•'Nacom9e2 and .son COMPANY ADDRESS Sox 66 oa;) or c cy 20 stI LIP Street Town COMPANY TELEPHONE 008 ) 775- - 3338 FAX ( 508 .) 790 ' 1578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a this address and that the information reported is true ,. accurate, and omplete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent . with my training and experience in the proper function and maintenance of on. site sewage disposal systems , : Check one: XXXX Systeui PASSED The inspection which I have conducted has not found any information which indicates that. the system fails to adequately protect public health or the environment as defined in 310 CMR. 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have co:n toted has found that the system fails t Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART..C -.. FAILURE CRITERIA of this i ectio for ,4Z oaf Inspector Signature Date copy of this certification must -be provided to the QWNER, the. BUYER On0where applicable ) anti the' . BOARD OF HEALTH. , * I-f the inspection FAILED, We owner or operator shall up.grade ' the system. within o'ne year of the date of the inspection, unless allowed or required otherwise as provided in 3;10 CM.R 16 . 305 , „4,a 14 COMMONWEALTH OF MASSACHUSETTS .\ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION d Y yt •.- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner's Name: THE CLANCY FAMILY TRUSTEE Owner's Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Date of Inspection:2/6/01 Name of Inspector: (please print) , JOHN GRACI RECEIVED Company Name: -,SEPTIC INSPECTIONS Mailing Address: :P.O.BOX 2119 TEATICKET,MA.02536 FEB 1 6 2001 Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF bAHNb I ABLE HEALTH DEPT. 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 Passes _ Needs Further valuation by the Local Approving Authority Fails Inspector's Signature: ` Date: 2/6/01 his inspection report to the Approving Authority(Board of Health or DEP)within The system inspector shall submit Lopy of t 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. Notes and Comments `r THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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. Title S IncnPrtinn Fnrm Aii snnnn I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 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: THE SYSTEM PASSES TITLE V'INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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'fa lure 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 1or!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 xp ND e lain: 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: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 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:enviroriment. 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 mannerwhich 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: " I _ 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 wat�i'. 0y. _ 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 SA9 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 use&to determine distance n/a "s '` performed at a DE certified laborato for coliform bacteria and This system passes if the well water analysis,p rY� 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 143 MISTIC DR.MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: 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 ''/I 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 1 M. _ 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.] (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. d Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 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 battles 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)] L 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Nuinber of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.20l (for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no): YES 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)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/ggpd Basis of design flow(seats/persons/sgft,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:Sr/a Last date of occupancy/use: n/a OTHER(describe):n/a GENERAL INFORMATION Pumping Records Source of information: 1997 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: 1986 Were sewage odors detected when,arriving at the site(yes or no):NO ' Page 7 of 11 is OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 BUILDING SEWER(locate on site plan) Depth below grade:30" 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: 24" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age co#f rmed by a Certificate of Compliance(yes or no): NO(attach a cop of certificate) Dimensions: 1000G L 8'6"H 5�t 7"N 4' 10"" Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle:33" I Scum thickness:0" 4 Distance from top of scum to top of outlet tee or baffle:6 l �— Distance from bottom of scum to bottom"of outlet tee or baffle: n/a t How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle c dition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): . THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SEPTIC SYSTEM'S EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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 g q Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 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.): THE DISTRIBUTION BOX IS`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 y R f - Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 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: 2 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: nla n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system 1, Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PITS APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. 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 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 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. ve 4 o � 0 �ab 1n Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 MISTIC DR MARSTONS MILLS,MA 02648 Owner: THE CLANCY FAMILY TRUSTEE Date of Inspection: 2/6/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+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 NO 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 excovajors,installers-(attach documentation) YES Accessed USGS database•&plain: n/a You must describe how you establish4the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET is si • 4. 11 SEWAGE INSPECTIONS LOCATION i4 3 , ci� cC _ D, ` - DATE Va,�AG£ y ASSESSOR'S MAP & LOYU_1 o5 O -INSPECTOR? o- SEPTIC TANK CAPACITY h- 0 :LEACHING FACILITY: (ty L' (size) NO. OF BEDROOMS BUILDER OR OWNER OWNER MAILING ADDRESS _ 1. F II TOWN OF BARNSTABLE v LOCATION 4-r'�5-0 C SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.,,AW If1 SEPTIC TANK CAPACITY f 00 LEACHING FACILITY:(type) �Q�l,/�P7� �/Q (size) 4!5�0�G-4C- a NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERZ�N O BUILDER OR OWNER DATE PERMIT ISSUED: �� ,� DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r _ _ �o i ;SO ,es ��r 2, 10 N 0 10 31 ti 11,E TOWN OF BARNSTABLE LOCATION 1 1 's fI SEWAGE # VU:LAGE (hn(S �I�Y�►_I I S_ASSESSOR'S MAP & LOT GICI �5 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY "LEACHING FACILITY: (type) (size) NO.OF BEDROOMS C BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet IL Furnished by �tv A q� IqL eck A AB rti O Q cy�G No:--.. a INSTABLE ��GSS THE COMMONWEALTH OF MASSACHUSETTS BOA RD I DVMEX& i q q—' 13�5- To�crk►.. ....................0F..........��l. a.i.. Ct e .................................... _----- Appliratilan for Diipusal lVarks Tianotrnrtiun Vitrntit Application i heretly made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal system at: -� -A�(�3 .!g.T .`'Q / Q�'•5. ..1._:_:.i//. ............. ..... --• ... ---•----..... Location-Address or Lot No. W Owner Address a .........-••--------------------------------------------•••-.....•••---.................._........ ------•-•-•----....-•------------...--•--....--•-••---....................._................_..._. Installer Address U Type of Building ! Size Lot...1KK.d!?_e..Sq. feet Dwelling—No. of Bedrooms.................,!........................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building — ( ) —Type g ..................•---_----- No. of persons----------------------____-- Showers ( ) Cafeteria d Other fixtures . W Design Flow....................... SS..._............gallons per person per day. Total daily flow._._.._....' vq..__....__.__._....gallons. WSeptic Tank—Liquid capacity4Z.S'r1..gallons Length/�__=_o.. Width 5'%o v Diameter................ Depth) .�.7'' x Disposal Trench—No. .................... Width.....--------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-._---__z_-_-__-- Diameter.,!-?.�ne*.".. Depth below inlet..y _o.".. Total leaching area,47Kj;..sq. ft. z Other Distribution box ( ie) Dosing tank ( ) r—a _y2,'7 ?i aPercolation Test Results Performed bye/ �1 ��__ r,..CQ•---•%••�_---•••_-•----_•. Date_/y4�-.-.�1�...1�,�'S. P Test Pit No. l......A......minutes per inch Depth of Test Pit.!A. c Depth to ground water•___ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .-••-----•---••-•---••••---••-•------••------••-...-•--•-......--• -•--•..................................•----•----••-----•------.............---•------••. O Description of Soil.... ��a.!!d.. syaso..�........ o�.�� `?�4' ''ear ....................................................... v3 i Z''.............e ni .-f........_ ' 1 ——/f.. W .................... ............ Q /_OlI.NaF.��!st_T�/'. -----�Ar_cov_4.Al,r,C,C-..._.....--•----•--•-•-----.......----•••-- 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 iITI.E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board of health. Sign d..-•-•••-- -- .--- ....... . o l... . ............ ... .......Date ...._.... Application Approved By............................ ... .......... --------......--•-- ..............� �� Date -----•---•. Application Disapproved for the following easons---------------------•----------•-----•-------------••-------••-----------------•---............_...------------ ...••---.......•-•...................................•-••----...--•••-------------......---..._.....-----•-----•.....----------....-•••-------.....-•-•---------•••----.........••-•---•.....----------- Date PermitNo......................................................... Issued....................................................... Date 'TIEw.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....Q W n.......................OF........................................T�f Applira#ion for 13ispos ai Warks Tonstrn.rtion amit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: �.�i.. �..� �../'v c ....... .......................7r �J.//Z.....................•--•--••---•--......................_........_. Location-Address or Lot No.,• Owner Address W Installer Address Q Type of Building Size Lot...'y c_v o ..Sq. feet Dwelling—No. of Bedrooms................:!�/_......................Expansion Attic ( ) Garbage Grinder ( ) p.l Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q1 Other fixtures ----------------------------------------------- W Design Flow.................... s.�_...._.___..gallons per person per day. Total daily flow...........'�-��-- o....................gallons. W Septic Tank—Liquid capacity6z�Ggallons Length �. U... Width.�_.''U... Diameter________________ Depth_-5-. -7" x Seepage Pit No........__--_____..•--_--_...... Width.................... Total Length.................... Total leaching area....................sq. ft. Disposal Trench— °� ' Diameter. K.._ _ Depth below inlet..'`'.' _..... Total leaching area_.S6... sq. ft. Z Other Distribution box ( x) Dosing tank ( ) - y z V 7 aPercolation Test Results Performed by.4_l<l.?'I e..�fn 2t:n... q..._--^ ................... . / Test Pit No. I.......�......minutes per inch Depth of Test Pit./Z..:. '._.. Depth to ground water-__- 114 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................. 9 ----------------------------------------------------------- -------------- ---------------- •---------- -------- -------------------- ....... .. ------ D Description of Soil..... .'.. ' u� h--,/ �t.•. c c/� - y��/�.�/s V `.. ----•••••• / -------------------------------•-------------------....... 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 TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d by the board of health. Silk ..•• -••-• -------•----------- ••_... ........... ................. �JJ3} �I V �a Application Approved By............................. __ Qj g Date Application Disapproved for the following easons:--••-•------••••-••••-•-•---•-••••••---••••-•-••-••••-•---•-•-••-•-•--•-•••••-•••-•---•----•-•-•.............._ ...........-•------------------•---•------------......--------------..........------.........------....---•-••-•-•-•--•-•-•---•--•-•-•-••-••----•-••--••••---••••--•----•-------••-•••••-----••••-•----- Date PermitNo......................................................... Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ �1n1.................OF............... = ......`t-* ........... +,.;(Irriifiratr of Tautpliattre THIS IS=T.O CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) t ly �` c .' t .... t. - Installer at.......... ` .w--�.......�._......-.m "�. -....... . ----C 3---------------------------------------------•--------------- has been installed in accordance with the provisions of TI 5 of The State Sanitary Cod s described in the application for Disposal Works Construction Permit N o............... f T - ---�---"��----- dated..---------- r.V------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... � 1 - Inspector........................................................•.--•-- -••-•••--•-•••-••••-•-•-...-••-•------......•-----.--- THE COMMONWEALTH OF MASSACHUSETTS BOARD -OF_HEALTH No......................... FEE........................ Disposal Wor onstfr�n rruti� Permission <s hereby granted ------------••.._.�..... ---•. ....-. ............................................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System • at No............. •••-••••...........•. -- -------r.;:.S at---...----�fki+1..E_Str --M-�--`........................... Street as shown on the application for Disposal Works Construction Permit No..�6..'".s�._�_ Dated.... . ..... ............ .R ................................................... --------------------------------•- Board f ealth DATE.. ...................................-.............. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS.,. r� O I�I - J44� I • r. 0 Pf-N DE.LET•E J - 'DOOR I Ir n I ads frRe E coL.. Amp.. 305`3D' RAr.ue+bf wtitx Ar 56 K IO"GOQt- PAD G c h o CPS avv(, T C� W AGLEig Te 5T'l92AbE rr� P/ Dock c-u r To F/T (U`Y� ry W /1P4E-aJ LDFT AA—EA 0 = rvEw �x85 OU•E 2 /�^oc. Cj m 3 Via'K�-E w��•�-S'r'- , 1 i S��a aDg6 1 8.Z�p Exlsrr�rq lsT Ftoo2 Pti}nJ = Se-A as-0" NffrJ O^r o F&oore OL;4W- 5 Z.A a C- . k , i 300.00 S 30*05 120"1✓ LOT 50 f 45, 000 S . F. PRECAST CONCRETE _ LEACHIAA Pw i` INV. IN 41. :'5 ';j\ E4 ,. },f P,Cc"CdST CONCRETE /O INV. 42.90 4CHING PIT INV. IN 40.59 i b N 30'06'20"E - / 300.00 PRECAST CONCRETE DISTRIBUTION BOX 1250 GALLON INV. IN 42.45 PRECAST CONCRETE INV. OUT 42.33 tic TIC TANK INV. IN •02.68 INV. OUT 42.51Aw w �Q f f^4, , A S BUIL T SEP TIC S YS TEM - LOT 50 L OCA TED IN 1. i BARNSTABLE MASS. iz13 mlsrlc v/.?. PREPA RED FOR �ro,�.a /ctS CAMMET T CONS TRUC TION CO. SCALE.' 1 "=20 F T. PLAN N0. 101786 DA TE. OCT. 17, 198E FILE NO. 194BA 20 15 10 5 0 20 40 . 60 :_ : DRA WN B Y.' HP N. B. NO. IL CAPE & ISLANDS SURVEYING INC. SCALE IN FEET "3 ' " ^ ''f� 131 SPRING .BARS ROAD _ TEA TICKET MASS, A_ _77 ;rEm PR E%, -A j. AL 77 4 �NO TO`!��7 a Top,I DAI F 7 FlN:r.4714�GRADE, .:'FtAlISH'GrqADE� 'OVER EL FtNtSH�'gRA DE, 0,VER FrNISH GRADE 0 VER "J.K. PTr BOX A, SE c 4'� '//A\\'(Arw%wll�k\w LEACktNO)OIT '\\//A\X RIES AN /Z S, X V7 A— op it PRECAST CONC ' OR SHED PEA S TONE �j ' !)T 0 L BRICK 491,NOR TAR TO 12" BELOW GRADE Elp'_PIPE L E VEL��, P -'-p FT.� MIN oz 4. A' -4. 7 alp. Z�6 -T OR PVC,.,. EES .4 A Ift A 9�0 OX, �UA is U' -TION �O B m Ft S T LL N 74 D TRIB S T'l ME2 - 1 - . - - - , , _ I I - 4. 11 1 701�4 1/2 00, TA ON�IE ,',BA SE, .3141 . CONCRETE ' WA SHED,. S!�. PRECAST �:CR SHED CONCRETE U 'STONE 40 H— 40 REINF EP K Trc TAN �INSTALL-- ON LEVEL,-BASE.' 40 NOTE:- EXCA VA TE."TO'. ELEV OR -TO REMOVE A L LIMPERVIOUS L OYER -F 4 ; J4, :;AfA TERIAL TH THE,�LEA CHING. AREA REPL ACE E) CA VA TED:'.MA TERIA L YrTH v Y, �FREE SAND : .... .... ... EFFEC TI VE DIAMETER 7_ GENERA L m r L EA CHING T NO TES Off ,L E VEL BASE INSTALL ' ALL E EVA TIONS Sk N ,, i0m, A*RE:BASED� ON .4z�� ` �PP� ALL PIPES "IN. THE,S YSTEM' MUST BE CAST 'lRON 07 0 VC 086 ER VA TION PIT OR SCHEDULE 46.. 0 HE BOARD EAL T S T BE NOTIFIED T :OF H H ,MU 0 klHEiV -P ,CONSTRUCTION IS: commtTt Rraq k TO' BA CKFIL L ING RCOL A TION RA TE., PEI Ck 4., "ANY ANGES rN .:.THrq :PLAN MUST. BE APPROVED MZN.'11N. B Y:, THE, 'BOARD OFJlEALtH AND :CA PE�'R ISLANDS WITNESSED B Y.' SUR VE YING CO JNC. 4� :5.::� MA TEPIA L S, A 1VD INSTALLATION SHALL ,.BE'Iff , 7 ... COMPL 'VCE 'Nr TH BRD. OF HEAL TH RIP) ,THE STATE: SANITAPYi,� DESIGN DA TA oo, AND LOCAL- 'APPLICABLE rAi DA TE: T_ AS Y A CODE L Ciq TITLE' V t 40,r 75 : " _ 1 1,�l .. . 1. , . I . I . . RULES AND�REGULA77ONS - ,.z . ,.. .. L %.�V6.3011 Pt NUMBER OF BEDROOMS- ARROW IS FROM �RECORDI k�, AND, -BE USED -PURPOSES DISPOSAL IS,NOT TO OR GA PBA GE "oo -dlovc. 7-.! , FLOOD HAZAADI Ze, ZON DAILY FL OjW B. 'NA TER 'SUPPL Y -7 g PTIC TANK REO 'D SE o pq SEPTIC �' TA NK PROVIDED RTCAST CCM.7-7AME LEACHING REGUIRED m v ir (v 5� AV S.F. SIDENALL AREA 1-'07 S.F.X G/S.F. 0P0 7 S.F. 80TTOM AREA , LEGEND. *�S.F.X I-e 6P0 q0 _01S.F. 4- GpD e 67 LEACHING PROVIDED TIOIV' . PROPOSED 'ELEVA, ZIP 9, , SINGLE FAMIL Y 'RESIDENCE & 06SERVA TrON PIT ............. kA A Drsmhqurram Box �jk Gr PROPOSED SEPIA GE L S%I'nTEM PREPARED FOR rT 2M9: 7� /Jr-m 0 0 r070 SEPTIC TAN, CAMMETT CONSTRUCTION� % RPi pESER VE LOT 50 MISTIC DRIVE 'MIL L S MASS BARNSTABLE M. ' -P Iec, , VER T'EL E VA TION Ln, DA TE. ,,IV4p V, r CAPE & ISLANDS SURVEYING, INC. PLAN -11,3.!017. 3 OF r rL EA 40 SCALE- AS NOTED �SCALE- 1 _Y4 P. 0. BOX 334 AP SEC 'LOT HSE -LOT , TE MASS. 441 A.rICII%E,T... =AN NO-.