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HomeMy WebLinkAbout0197 MISTIC DRIVE - Health 197 Mistic Drive Marstons Mills - - - A = 079 054 - y t Commonwealth of Massachusetts � -OS / O�✓ a r Title 5 Official Inspection Form ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t x� 197 Mistic Dr tg Property Address h,.1 Nadia Pokrovskaya Owner Owner's Name information is ✓ Y� required for every Marstons Mills MA 02648 9-14-18 r�. 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. A. Inspector Information '1333e3 Shawn Mcelroy Name of Inspector Wiper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation-by the Local Approving�Authority 4. ❑ Fails 9-14-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form { w'' • i�l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection . C. Inspection Summary Inspection Summary: Complete 1, 2, 3;or 5 and all of 4 and 6. 1) 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: System is in good working order with no sign of failure. r 2)' System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass"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 exhitration 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 ON ❑ ND (Explain below). t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i Commonwealth of Massachusetts j Title 5 Official Inspection Form N Subsurface Sewage Disposal System form -Not for Voluntary Assessments � c 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or breakout 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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 wi I pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y El ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 15 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form w: � i01 Subsurface Sewage Disposal System Form Not for Vol u ntary'Assessments - 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes- No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 ';. Commonwealth of Massachusetts �y Title 5 Official Inspection Fora hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� ,r 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 :N Commonwealth of Massachusetts Title 5 Official Inspection Form i�t Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is Marstons Mills MA 02648 9-14-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? ® Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora ill i' r► Subsurface Sewage Disposal System Form Not for Voluntary Assessments. y 1:0. 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-2014 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts " Title 5 Official Inspection Form ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Owner--pumped 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I N Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 9 p Y rY 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is Marstons Mills MA 02648 9-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool . ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed if known) pp g p ( n wn) and source of Information: 2003 Were sewage odors detected when arriving at the.site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: , F ❑ 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.): Good condition. t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 4� Commonwealth of Massachusetts rg Title 5 Official Inspection Form w1 b1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is Marstons Mills MA 02648 9-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 14"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 gal H-20 Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1 rr 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 How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no,sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts f Title 5 Official, Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below glade: 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.): • 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below g-ade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 'ec , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments ;> 197 Mistic Dr Property Address Nadia Pokrovskaya ` Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes - ❑ No Alarm level: Alarm in working o king order: ❑ Yes ❑ No Date of last um in : p p g Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present.must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Video inspected and in good condition with water at working level and no sign of back-up from field. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts a , Title 5 Official Inspection Form } ^ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,,explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: I ❑ innovative/alternative system 'Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >`'J 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition and holding 3" of water with no visible stain lines. 12. 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.): t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � K i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , 13. Privy (locate on site plan): Materials of construction: Dimensions r Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I�Q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ,ram. ' . ' q UA 137 r r r 1r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form HI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 124 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 property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 s Commonwealth of Massachusetts ,w Title 5 Official Inspection Form C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Dr Property Address Nadia Pokrovskaya Owner Owner's Name information is required for every Marstons Mills MA 02648 9-14-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist, Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 9 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON, MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: U key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service QCompany Name 17 Playground Lane Company Address Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S14454 Telephone Number License Number B. Certification a 1 :J I certify that I have personally inspected the sewage disposal system at this address and that they-'i information reported below is true, accurate and complete as of the time of the inspection.T/he 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/11/14 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. I I I t5fns•3/13 Title 5 Official Ins on nn:Subsurface Sewage Disposal System•Page 1 of 17 J � a ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner owner's Name information is Marstons Mills MA 02648 6/11/14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑x 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old` or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON, MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y .❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. , ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑x 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 ❑ ❑x Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 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. ❑ 0 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. ❑ N 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 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 ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health Cl 0 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? ❑ © Have large volumes of water been introduced to the system recently or as part of this inspection? FX-1 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ' ❑x ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑x ❑ Was the site inspected for signs of break out? ❑x ❑ Were all system components, excluding the SAS, located on site? ❑x ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑x ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ❑ ❑x Existing information. For example, a plan at the Board of Health. ❑ 0 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): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes © No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑x No information in this report.) Laundry system inspected? ❑x Yes ❑ No Seasonaluse? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): na Detail Sump pump? ❑ Yes © No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 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 O No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Ma tons Mills MA 02648 6/11/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑O No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑cast iron ❑x 40 PVC ❑other(explain): Distance from private water supply well or suction line: 10'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 1' feet Material of construction: 0 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 gl Sludge depth: 3" ens•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "Y 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4" 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 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 2 years.Inlet 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 t5lns•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 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 four outlet lateral.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.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: leaching chambers number: 4-1-C 500 ❑ leaching galleries number: ❑ leaching trenches number, length: Cl 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. Leaching chambers had 6"of water at time of inspection. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner owner's Name information is required for every Marstons Mills MA 02648 6/11/14 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON, MELISSA L Owner Owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached,separately I i � Finn ,M y 14 �cs 3 � i t5irs-3113 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 197 Mistic Drive Property Address COTTON MELISSA L Owner owner's Name information is required for every Marstons Mills MA 02648 6/11/14 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope Surface water. ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 33' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) O 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 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 197 Mistic Drive Property Address COTTON MELISSA L Owner Owner's Name information is Marstons Mills MA 02648 6/11/14 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked 0 Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ❑X System Information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 No. W 3-00& --oil Fee---,5 /----- BOARD OF HEALTH TOWN OF BARNSTABLE 0pplicat ion-for lVelr Con5tructionVemit Application is hereby made for a permit to Construct ( I), Alter ( ), or Repair ( )an individual Well at: 7 ' Location — Address Assessors Map and Parcel e %�---___.-.-_------ Owner Address j Installer — Driller Address Type of Building Dwelling --- - -- ----- - Other - Type of Building------_- .---_._____ No. of Peersons_-------_-------_------ Type of Well C �c-_ --�-z- Capacity-----r--�`__� —_------ Purpose of Well 4 A4-! '-- =��=---�_- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of He Pri ate We to egulation - The undersigned further agrees not to place the well in operation un ' a I c as been issued by the Board of Health. Signed ---- -- -- � date Application Approved By _ __ __1t_—___— r✓G _._ dte y Application Disapproved for the following reasons: -----------------_—___—.. __ __—__ date Permit No. l/J __ L( Issued date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by--- ----------- - -- Installer _-- a t-__ — _-- ------ --- - --- -has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------------Dated---.-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector------- _-_- ---- ------- No.-------- Fee-------------------- BOARD OF HEALTH !I TOWN OF BARNSTABLE rC, 0pp[icat ion-for Vell CongtructionPermit Application is hereby made for a permit to Construct ( t, AIter ( ), or Repair ( )an individual Well at: 4-1 Location — Address Assessors Map and Parcel Owner— ---- / Address t � � ,-� ----------- - --------------- --------------- - - -- Installer — Driller Address Type of Building Dwelling----------------------------------—--=_— Other - Type.of Building------__—___—____.+ No. of Persons---------------.______—__—_--_ Type of Well Ca acit /s-�—<n r Purpose of Well.--- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well�r.tecti6�egulation — The undersigned further agrees not to place the well in operation until'a Cer - >cate .of C m i c�S e-"has been issued by the Board of Health. / ��G �t Signed -. -- --------- ------ -------date ------- t Application Approved By 0tZ __ __ r__ G__-__—__ date Application Disapproved for the following reasons: _— --------- ---- - —-—--------------------- - —— -- —__ _— date Permit No. 1 nl_a 00 6 —�� y — --- Issued b 0 A(, r-- — -daatt -- — —------ e ----------------------------------------------------------------- -------------------------------------- BOARDyy <Y OF HEALTH TOWN OF BARNSTABLE r Certificate Of Como[iance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by---- ----------_--------------------- �----------------------------------------------- Installer at___— ------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -----------------------Dated--------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL I' SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - —-----— - —-- Inspector--- - —------------------------------- - i ------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con5tructionPermit No. —Ire Do L — O Fee— Permission is hereby granted— �y tom& J,p_L —_ __ — to Construct ), Alter ( ), or Repair ( ) an Individual Well at: No. 41-2_ - street as shown on the application for a Well Construction Permit No.- — — Dated -- - ---------- DATE �� r a 1���_—_ Board of Health USE (4) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) WITH 3' STONE AT SIDES AND 2.5' AT ENDS 72.9 + 7C 77 + 71.6 • o/ 70.9 76. 79.9+ + 79.7 + 70.7 Oj PROP t �— -- --I X. ._. — DRIVEWAY \ 7 70.2 80.0' 82.1PROP. W I/ ui DWELL., II o 1' W 11 // + 70.2 TH 1 0 r , \G� TF = 81.0 I f 1 a 1 w 1 op / ti +:70.0 80.5 I I a ' Of \ 1 � N 3 .9 1 I 1 q Q Qom j ' / 1 Q I 69.8 I 1 O � o f } 78. \ 1�9.8 o f pl? 80.1 It TH2 + 70.3 - f 7 W 69.6 LOT 47 44,834f SQ. FT. 1.O3f ACRES f 16 + 77.�9 ,� ,� 75.0 ^� n � � 69.5 249,29' off 508-362-4541 fax 508 362-9880 non wn i -n nP . PnninPerino, inc. s COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION < �IO'M Sy,'� ix.•, { TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ' E i C=3 Property Address: " ,/ rye/ A A Owner's Name: �F Owner's Addre ,'// &)- Cn Date of Inspection: 4h ' .f _)•�' ;; Name of Inspe t9r (please rint) t.a r Company.Nam CAl�>> R' r ri Mailing Address: Vr�A r . Telephone Number: - /- 24�_) 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.a's.cif 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: V/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: — Date: S��G kU 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. {. Notes and Comments_ ****This report only describes conditions at the time of inspection ar_d 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 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS j r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property.Address: Owner: Date of I ection: .� Inspection Summary: Check A,B,C,D or E./ALWAYS complete.all of Section D A. S stem Passes: 1 have not found an information which indicates that any of the-failure criteria described in 310 CMR Y Y 15.303 or in 310.CMR 15.304 exist.Any failure criteria.not evaluated are indicated below. Comments: B. System Conditional] Passes: Y Y 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 or tank failure is imminent.System will pass inspection if the existing tank is replaced with 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 yea_s old is available. ND explain: Observation of.sewage backup ar break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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): brol'en pipe(s)are replaced obstrurtion is removed ND explain: 2 t Page 3 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 _. 4 Owne Date o spection: C. Further.Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board o-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 accordancewith 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 priory 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.]00 feet of surface water supply or tributary to a surface water supply.. The system has a septic tank and SAS and the SAS is withir_a Zone 1 of a public water supply. The system has a septic tank and SAS and the.SAS is withir_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 DEEP 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: 3 Page 4 of 11 OFFICIAL INSPECTION-FORM—.NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: OwneC Date off pection: rkftf D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all inspections: Yes N .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 d Liquid depth in cesspool is Iess.than 6"below invert or available volume is less than ''/z day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number l/ of times pumped Anyportion 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. „ .V/. Any portion of a cesspool er 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. t/ 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, �l 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)03�,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;004gpd to 15,000 gpd. You must indicate either"ves" or"no"to each of the following: (The following criteria apply to large systems,in addition to the criteria above) 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 quesiion 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. 4 Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / Owner a Date of pection: / Jms ' Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Y0 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? as 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 bark up? Was the site inspected for signs of break out? AZWere all system components, excluding the SAS, located on site ?. Were the septic tank manholes uncovered, opened, and the in=erior 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 owne-)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 Existing information.For example,a plan at the Board of Health. V — Determined in the field (if any of the failure criteria related tiD Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM-.INFORMATION Property Address: Owner: ' • Date of pection: ' FLOW CONDITIONS RESIDENTIAL. J� Number of bedrooms(design):_ Number of bedrooms(actual): DESIGN flow based:on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):3 Number of current residents: Does residence have.a garbage grinder(yes or no):/ Is laundry on a separate sewage system(yes or no)✓vo.[if yes separate inspection.required] Laundry system inspected(.ye .or no):/ Seasonal use: (yes or no): (� t Oa) �._ 'T W Water meter readings, if ava,ilable(Fast 2 years usage (gpd;): �7 1 Sump pump(yes or no): � /�9���,,; � �� ✓� o „. �n���y� Last date of occupancy: C/ 'r-4t C (e(�'✓-C.0 COMMERCIAL/INDUSTRIAL!/ Type of establishment: 10 Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft;e_c.): Grease trap present(yes or-no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Titl-2 5 system (yes or no):_ Water meter readings, if available: Last date of.occupancy/use: OTHER(describe): GENERAL INFORMATION - SourePumping Records ` Source of information: ., 1/() ® � ✓ 4 w Was system pumped as part of the insp?c io (yes o o):-A-10 If yes, volume pumped: gailons--Ho.w was quantity pumped determined? Reason for pumping: T7OF SYSTEM ptic 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): {� proximate zge of all cod.Pon nts, date installed(if known) and source of information: Were.sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEIVI INSPECTION FORM PART C SYSTEM.INFORMATION(coc-tinued) Property Address: ,�7 ° Owner: Date of I ection: BUILDING SEWER(locate on site plane) Depth below.grade: Materials of construction:_cast iron - 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK:A—/(locate on site plan) o Depth below grade:_� ,. Material of construction:�oncrete_metal_fiberglass_ polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /�• �� ° Sludge depth: Distance from top of `y dge to bottom of outlet tee or baffle: Scum thickness: _ P/ Distance from top of scum to top of outlet tee or baffle: Z Distance from bottom of scum to bottom'of outlet tee or baffle: How were dimensions determined Comments(on pumping recommeeFatttondin®let and outlet tee or baffle condition, structural integrity, liquid levels rel.ated to outlet invert-evid ce of I akage,etc.): V >C GREASE TRAP locate on site'plan)' Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom:of outlet tee or baffle: Date of last pumping: . Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage; etc.): 7 Page 8 of 11 OF FICIAL INSPECTION v FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Propert Address: Owner. ' r Date of spection: TIGHT or HOLDING TAN f.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: gallonvday Alarm present.(yes or no): Alarm level: Alarm in working order.(yes"or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet inve_t. Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of --teakaPento or.out of box, c.)• go PUMP CHAMBER//(locate on site plan). Pumps in working order(yes or ro): r Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Paze 9 of I 1 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. � SYSTEM INFORMATION(continued) / /j Property Address: �Q Owner: Date of I ection: SOIL ABSORPTION SYSTEM (SAS): lzoocaie on site plan,excavation not required) If SAS not located explain why: Type _ Le'aching pits,number:_ Teaching chambers,number: leaching galleries,number: leaching trenches, numberjength: leaching fields,number, dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of por_3ing, damp soil, condition of vegetation, ec CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan) Number and confiouration: 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of por_ding, 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 por_ding, condition of vegetation, etc.): 9 Page 10 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: jA )L?14 Owner• ' Date of spection: SKETCH OF SEWAGE DISPOSAL SYSTEM - Provide a sketch of the sewage disposa- system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within _00 feet.Locate where public watee supply enters the building. 1 tu Soo )(IIon 1 ahara be 10 Pace 1 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1 Property Address: J . Owne ( � Date of pection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water j feet Please indicate(check) all methods used to determine the high -round 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) o/Accessed USGS database-explain: You must describe'how you established the high ground water elevation: i 11 Permit Number: Date: Co-npleted by: HIGH GROUND-WATER LEVEL COMPJTATION Site Location: Z 15 /G All /o4Lot No. Owner: Address: Contractor:_ All- 0�/ �GfS� Address: Notes: STEP 1 Measure depth to water table / tonearest 1/10 ft. ............................................................. ............ ...... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map IDcate site and determine: OAppropriate inde :well............................................ ✓ ., . B Water-level range =one ................................... C - STEP 3 Using monthly report:''Current Water Resources..Cond tions" determine current depth to water,level for index�i�ell �J� 051 q month/Year STEP 4 Using Table of Water- Evel Adjustments for index well (STEP 7A), current depth to water level for index.well (STEP 3), and waterdevel zone (STEP 2B) determine water-level a a djustment ...................................... .............................................' STEP 5 Estimate dept'rr to high water by subtracting the water- level adjustment (STEP 4) µmy from measured depth to water - level at site (STEP 1 i Figure 13.--Reproducible computation form. n - s Y .. y � 15 i ITI " rdnox .......... ;.......,,._..._.,,,.. ........... Oi��'�i�P.�l`�(!I Gig: (.'(r'r .__._�.__...._........_..,....... I � . • I I .� I TOWN OF BARNSTABLE LOCATION SEWAGE #Z YII,LAGE ASSESSOR'S MAP.& LOT I INSTALLER'S NAME&PHONE NO. d .�o ���' n li► .5 I � SEPTIC TANK CAPACITY I �3 (o t �0,) LEACHING FACILITY: (type),q (size) NO.OF BEDROOMS BUILDER OR OWNER 1' PERMITDATE: Z — 1 =-0 2, COMPLIANCE DATE: lets/ 6 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I , Elm -� r ® � f No i�lG���j =06 Y+ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: z—a-/ r Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mizpooal *pgtem Construction 3permit Application for a Permit to Constrict( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. u�� P Owner's Name,Address and Tel.No._ Assessor's Map/Parcel Q J Ca Installer's Name,Address,and Tel.No. 1I Designer's Name,Address and Tel.No. Type of Building: !)c 5,S4-Fof Y Dwelling No.of Bedrooms Lot Size 44.$'6'� sq.ft. Garbage Grinder( ) Other Type of Building RES�t*si.4c_T4*""No.of Persons Showers( 2) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow L/Lf C) gallons. Plan Date IN 17/C.-L Number of sheets 1 Revision Date t T-J 3/e1-7_ Title Size of Septic Tank 1.coo (ZA k- Type of S.A.S. Description of Soil �tPM Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure th construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of ' 1 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bALis Board of HkSignV Date Y G Application Approved by Date--- Application Disapproved for the following reasons Permit No. Date Issued --------------------------------------- -41 No. Fee Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS t Yes PUBLIC HEALTH DI�/ISION - OWN OF BARNSTABL''E., MASSACHUSETTS, " 01ppYication for ;Dizpool *pgtem Cow5trucfiou'Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. 197 M Owner's Name,Address and Tel.No. t ski c ,(�� � Assessor's Map/Parcel O 5 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 5,t.�-cur- 7 Dwelling No.of Bedrooms '� Lot Size 44 $ sq.ft. Garbage Grinder( ) Other Type of Building RfS s1AL_T4^*""No.of Persons Showers( 2) Cafeteria( ) Other Fixtures Design Flow 440 gallons per day. Calculated daily flow �/�f C� gallons. Plan Date Number of sheets t Revision Date t zf B,oZ Title Size of Septic Tank (�� GAS- (� Type of S.A.S. Description of Soil Q(ll Ct AA La a C C S i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of T'd 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been's uer his Board of Heil.fit'' Signed Date 7 Ar A ` Application Approved by Date :�' Application Disapproved for the following reasons Permit No. - Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that�e On-site SevageDisposal tem Constructed ()( Repaired ( )Upgraded( ) Abandoned( )by ( 1 at � ./'� S o( . 1 has been constructe in Accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 200 3'005—dated _7 O 3 Installer Designer The issuance this permit shall not be construed as a guarantee that the syst wil functio)Qa -desig ne S Date 1—o-7, Inspector N No��� "O/( L/-------------------------Fee cCJ�77 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizpaar 6pgtem Construction 3permit , Permission is hereby granted to Construct�Repair( )Upgrade( )Abandon( ) System located at 1 2rl M G.fi c or-ve and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: � Co tru 'on must be completed within three years of the date of this fDate: O 3 Approved byDY i Dr^ °Vex, -- cci o LISTABLE _ L n SEWAGE W' . y ,,GM jVla�-s s % s Ass ss�ECS ttt .L 15 N ao SEMC TANK CA1aAC !'X � �S LEAC�III�IG:FACI€:I'� .( � C bf'rJ (si�e1 N0.OP IBEDRbON, B:X.= R OR t3W3+tER P'EITDI�TE CUlvl'?I.f�rIOE'DATE:' SoparaUon Dtancc Bet�resn the Feet Max�n}um Ad�ustet�Groundwatex Table to the Bottom of I,ea91 M2 Facii�ty Prsvate Stater SupP1y ITell aridt acb ng Fac luy (tF;any we 1s exist on sica of wltbin 2a0 feet df feaetting f icY} Fest Edge of Vold andleactiu$Faa'iity(If ariytetlatcLS exist Feet v�nttun 3t10,feet f &itig faalitY} 1/ � 7 FurWshed bY' _ __ __ ._._. lEo :EO k,,o 5* e R_5�r / 3 I oy [ ,4-1-,C9 410 A'3 TOWN OF BARNSTABLE LOCATION M7 //�l� 11 ✓ It(/[�' SEWAGE #Z� `ILLAGE �G�S'� ./.�01U ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY .5-n rp LEACHING FACII.=: (type) (size) :�� Q C NO. OF BEDROOMS_l-�/ BUILDER OR OWNER 1 S C .;1 I� PERMTTDATE: Z -1 —Q OMPLIANCE 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 Furnished by FNn --� "® o 10 C 2-1 , CGS w 14 R� GO'-01 13-8 1/2" 13-8 1/2" 3 2._S. TW284G TW301G TW3044 FWH9068 'FWH90G8 WHO SMH9 13-2 I/2" o❑ -SOLID MICR ID P��i����S OVER DOORSS i D©DWOOGi]-� S 1/2" X 1 1/4" AT HEADER 2448 (1) 1 1/2" X 9 1/4' IN ROOF SYSTEM aMHZ I/2'F/ 31'-8' . m � 1 OGi©p4 G300W � 3_, PROTECT rI1VG7•� I 3/4'F ❑ soffit flush with wing Walla rvE \ 3G BY OWNER aW r w a D j - ___-'----- ----- TG''bY ' 2H p= (D 1 I/2" X I4" MICROLAM IN ILING P) 1 1/2' X 9 1/4" MICROLAM IN CEI 3N -FLUSH CONDITION 0 8'-L' OPENING Ii —� 3' P HEADER ' 24G8 12) 1 1/2" X T" MICROLAM IN CEIL G ' ------- fl) 1 1/2" X I9' MICROLAM IN UPPER ('� F �------------- � PF i BIB star hel ea Nm a2HWB z = B42� -UBOOKCASE ---- -Zroot ell auPpp rung the BY OWNER mmroof over Chia module 'n D= to havetrl le studs toUiolnlchl�llooarge opemngaB92 EF34-3 [�R- ULL N TAIR9 O. /3' X TopN < 1 m 0 < O ° BLS W2 i ' ®^ T O IG'-O" 2GGB lOGB W3GI8� W213C WC293G 1 ; I I m � 1 G8 v 2G e I i 3 Z I i F V O' DN w W °: e. G8UU U' Iry ZN > 1 < W ®vo LL BMHL o - a �r i n O� N 2.1 2GGB T �? 1 X- W W - X O Q 3/4'F I'F W N 0 m N 1 Z f M a n F 3068 '� w vB3c ❑ ° ° ' O i S"3 33HWB fo m o LLJJ 3 3 U. Q©DGi00Gi]-�3 Q-9 4Hwe F m o a ©DGi00b-9 �; 1 TW304G o APPROVED ' 111 I I/2' X 9 I/4' MICROLAM I CEILING 1� PFS. CORP. - TW3044 iv o z 11 ws TW3044-2 FEB - 5 2003 Ll APPROVAL LIM►I'ED TO Drawing No. TW3044 TW309G I 91�,E34f.ISED 2/03/03 ON 3"-II I:'?' -0. q'-8 1/2" F CTORY BUILT PORTION USE OF THESE PLANS DRA CHECKED BY DRAWING DATE MA SCALE THOU?WRITTEN u PERMISSION FROM /'C /A LI IHUNTINGTON S PROHBITED.OMES.INC KL 12/23/02 ARCH FIRST OOP, VH 3/16" _ 1'-0" 1 TOP FNDN: AT EL 81 •0, SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER: D.A. OJALA, SE 780' MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 74.0' WITNESS: D AVID STANTON ` MIDDLE POND 2" DOUBLE WASHED PEASTONE DATE: 1 1/5/02 I f RUN PIPE LEVEL \ RuMe 77 0' FOR FIRST 2' 3' MAX. PERC. RATE _ < 5 MIN/INCH AVE PROPOSED 1500 rr-E GALLON SEPTIC71 0' CLASS I SOILS P# 10365 MIDDI£ I HAMBIIN POND �:75.75' I oND TEE PATH n TANK (H- 20 ) GAS \ '' BAFFLE 70.52' �� �`-700..3355- C7 0 O 0 70.17 F-1 = o c� o o a LOCUS MIN c� ao.o 0 ocacic� A ( 2 7. SLOPE) �6" CRUSHED STONE OR MECHANICAL $ 2' 0 0 E3 Q E] 0 68.17' ELEV. COMPACTION. (15,221 [21) MIN 0" 70.2' Q" 71 .2' ON \ DEPTH OF FLOW = 4 ( 14 % SLOPE) ( 1 % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE - - TEE SIZES: INLET DEPTH = 10" / 14" 4" 4" [-LOCATION MAP NTS OUTLET DEPTH = FOUNDATION- 13' SEPTIC TANK 38 Da" BOX 20' LEACHING ASSESSORS MAP 79 PARCEL 54 FACI;._ITY 8.97' • 24" 68.2' 36" 68.2' ZONING DISTRICT: RF w YARD SETBACKS: SEPTIC DESIGN: (GARBAGE U)SPOSER IS NOT ALLOWED ) FRONT = 30' DESIGN FLOW: _4 BEDROOMS (110 GPD) = 440 GPD UNSUIT. - UNSUIT. SIDE = 15' USE A 440 GPD DESIGN FLOW 72" REAR = 15' SEPTIC TANK: 440 GPD (2) = 880 59.2' 60" to PLAN REF. - PB 203 PG. 53 USE A ]-5-kCL GALLON SEPTIC TANK C2 FLOOD ZONE: C LEACHING: C2 2(39 + 10.83) 2 (.74) = 147 SIDES: MED/COS MED/COS BOTTOM: 39 x 10.83 (.74) = 312 TOTAL: 621 S.F.. 459 GPD TRACE SILT 10YR 7/3 USE (4) 500 GAL, LEACHING CHAMBERS (ACME OR EQUAL) WITH 3' STONE AT SIDES AND 2.5' AT ENDS 132"' 59.2' 144" 59.2' > > 72.9 NO WATER NO WATER NOTES: 4 NOTE: LEACHING FACILITY IS 25 NOT DESIGNED FOR VEHICLE 1 \ ASSUMED ,3,gp, + 72.8 � LOADING. IF VEHICLE LOADING . DATUM IS EXPECTED, PROVIDE H-20 3 ELEV. 77 / + 71.6 Q ' 2. MUNICIPAL WATER IS AVAILABLE �•. COMPONENTS 0'_ .- 71 .9 A 3. MINIMUM FIFL Pl I CH I U BE i/b" Pr r Civ 1. SL 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 f 70.9 4.. 1OYR 3/2 5. PIPE JOINTS TO BE MADE WATERTIGHT. 76. 1 B 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 20* j 79.9 + 79.7 ' LS ENVIRONMENTAL CODE TITLE V. + 00 + 70.7 36 1OYR 6/4 68.9' 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT _ _ _ _ TO BE USED FOR ANY OTHER PURPOSE. CO _ M T H. 40-4" PVC. u� i ( _ 8. PIPE FOR SEPTIC SYSTEM 0 SC • � TR. OF a �o ,� ,. ._.. _ 70 3 BENCH MARK C P = T B BACKFILLED OR CONCEALED WITHOUT 1 y PROP � � C.BASIN .ELEV. 70.1 9. COMPONENTS NOT 0 E _ DRNEyygY CPERMISSION OBTAINED F HEALTH TH AND cr INSPECTION BY BOARD 0 E L 7o.z 8. / '�"" - _ ` PERC FROM BOARD OF HEALTH. ^g MED/COS 10. WATER TEST D'BOX FOR LEVELNESS 80.0' 821PROP. I / 1^ DWELL. � cr �1 o / TH1 0 I w / + 70,2 �y � TF = 81.0' � 1 ►1 YR 7 3 ' SEPTIC TANK TO BE H-20 LOADING I I' + 70.0 10 � / / CAPABILITY l o• ] N 80.5 � 1 TITLE 5 SITE PLAN �3 .9 1 � q 4 � . Q Q� NOTE: SOILS ARE VARIABLE ON THIS SITE. 1 1 - 69.8 CONFIRM SUITABLE SOILS OVER ENTIRE O 4' BENEATH LEACHING FACILITY AREA FOR BE It ao a I Cti OF 'i FACILITY PRIOR TO_l INSTALLATION. IF TH 197 MISTIC DR IVE 80.1 78. � 159,8 O � I "1 UNSUITABLE SOILS ENCOUNTERED, EY � REMOVED AND ENGINEER TO i R T BE/ ARE 0 _ _ I CERTIFY SUITABLE REMOVAL. IN THE TOWN OF: \ _ TH2 126 61 .4 � / + 70.3 �; I " , ( MARSTONS MILLS) BARNSTABLE 7 NO WATER 1 PREPARED FOR: W 69.6 LEGEND JIM SCALI 0 LOT 47 un 44 834E SQ. FT. 0 30 60 90 1.03t ACRES I 100.0 PROPOSED SPOT ELEVATION 30 16 4,77 In75.0 ^� n 69.5 t 100x0 EXISTING SPOT ELEVATION + 779 SCALE: 1" = 30' DATE: NOVEMBER 7, 2002 1 2 49.29 _ 100 o- -0 PROPOSED CONTOUR REV. 12/3/02 (DWELL) off 508-362-4541 100 EXISTING CONTOUR fox 508 362-9880 OF Mf, ��N OF ,y ���t� ASJ9�� Inc, q dOWn CQ�7e engineering, �� s� �� gFNE ti�< � C o J- - .. . � ARNE H. �G CIVILENGINEERS CD LA o JA 8 BOARD OF HEALTH CIVIL ,o No. ,o LAND 'SURVEYORS 0.30792 � 16z- .6MA si o�� 0 N � m A A 939 main st. Yarmouth, ma 02675 APPROVED DATE JALA P.E. P.L.S. DA TE 02-348