HomeMy WebLinkAbout0274 MISTIC DRIVE - Health 274 Mistic Drive
Marstons Mills p
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19934 P0226 *40275
UF BARNSTABLE
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D-EIED RESTRICTIOP4
2005 JUN 28 AM 9: 58
TFIIAW.�_.,43, JAY H. TR_,kCY and CONSTANCE M. Trt NC"- r __ - x r, -1
Drive, Marstons 1011s, Nfassachu set ts, are the own\-.rs w'a parcel of land. locRVISION-4 -
Mistic Dr;ve, .Ylarstons Nfid1s, (Ijer IT
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after referred to as Lot 16) and bc-ing
shxAn on a, plan entiflcd "Indian. bakes J_Hlstates' Subdivision plan of 1.,vaidt 'In (�Iaystnns
Mills;: B.-unstable, Mats. fo-i A.D. Nfiiddlalen-j, Jr., alij Sarnes J. Cannoti. Sc.ale V - 100'
April 7. 19,1--i6 revised May 1. 1, 1•966 MeTC.CT Corp. SouvtI Varmo-wlh,. Ntass."
du;y filed with flarnsmble Couno,, Peglstr, of.!Decd.; in Flan Book203, Page
II
a-,-" 0","FS CE NI TII,.,A.0 Y a!-,; 03c mvners of IIEREII_�. JAY H. FRAC
said lot have agreed with the .Fow-, oC Barnsm� .,,le i3'oarct ofliealuh to a res(riction a,.;tt,l uh,(:,
number of bedrooms which car,, be irc'IuLd In -unv home- bu;'j't o-n sald k-)i as a pre-
cond't`on lo obta*Ti'ri!�, a -\-u iai-,c- c,,.rn the 0 Sta - Enviro-mmental Code,
I I I I v -NIX. 214 L J.__ I _ m.
'Title V., 1).4injimuni Req uiren-_ej.its. for tl-j,e Sulrsurfac,2 Dispr�)sal of Sanitary Se,,vage and to
Oblxulng a bufldi.ng pen,11,11 For this Ict;
RIIERE.4,5, the 'To�N-n of Barnst abie Board of Heait'h, as a pi'e-condition to
granting the va-m-unce from 310 C__I\,ff.R,. 15.2.14., State Envlxonmerv.al (_odc, Title V.
MInImurn Reauirei-nents fa- fhe SubsuifaCe Disposal of'Sanitaj Sewape, and authorizing
the Issuanoe of a buildung pemit for th construction of a si-ngle fanally home or) this lot
is requiring that the agreement for the restriction on the raunber of bedrooms in an,y house
coust.tucted on the lot 14)C PUT 011 'COCOrd with thc flarns:�ab)c Coura,,,- R.egislxy of Dettis b-y
ieex-ding this document,
YORE, JYV, H. "T'RACY and C'("IXT Q7 A'P,j C I-P,
NOW THf*RJ, J. , �I, �4. T A C Y dc;
b`wrebv place the following restnct;on on their a�Dovercfcrenced land 1r, accordance with
tlu's agr,::erment votb the Town ,-)FBarnsiablz• Board offlealth, vvfilchresb.-.Ic:tion shall MR
with the !and and be birldttl'G LIPOn al" SUCcess(A'S. in title:
274 'N, fikst-"c Drive, Nlarstons j'vfi'lIs5 may have constmctetd.
upon the, lot a house cotitaijum, ao more tha_-j iju-ce (3) bt-.d_rcv0.qiS.
Yr H. TP-ACI 7 and C0'_�STAjX'CE M. TRACY agree that Ihis, shall be a
7�
perrrianent do restriction affectinp. Lot 16 Iocated in Marstons IMil"s, Massachuslats,
7
and be-Inq shovvn on the )Lan recorded in Plac-i BmU 203, Page 53,
PROPERI-V ADIDRESS: 274 Mistic Dri-ve, NIarsOns Mills,
Fo.r tItie of *.I.k. y 1-1. 'TR.A.( ).r and CONSTAN(:E' 0. TRAC"I', see fmllovnil (deed: Book 1813 J, Page 2 and Boel: 11 9036. Page 74,-,�.
A:eeded instru"new daY of JU
E-ve,cuted ty,� a
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11 OF MASSACE1.
as
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i s3llsia(ACIr)
!o namt: i
Cal 011 WhIC-1] '111,1.as sac li-u�ev S 011ver's
-hat he s;12rn,,-,', ;t
�i id -hprt,c— ;,Ij ,it�zw ld
fur 11 zat.ed p.irpo;ri
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CONENIONAVEA-L-31"11
Barnstable, ss
I. un, i�r�,
orl �'l day of . Llf}c, 2()()) bci'
Plulbij,c, person.ally appea�-d Cons-zanc.tf N1. Tn�,c,,- Y-ne
be *,Eli' -persor,
dence of idtntihic-at,�,-)n Massachust:tis dn-�Cr s
liCf it
or d0,`L1j ;L and acknowled2cd 11) ;T!,-
WhOse naj:-ne Ys signed on u'le, prccud' I)el" and - k
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that -111,x sig-v-t'6 it v()11L111J--T"V f F
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
JAN 0 6 2004
11 5 N, 7 1
t,;,i-X,43 1
TITLE 5 E
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 274 Mistic Drive
Marston Mills, MA 02648
Owner's Name: Eleanor Panasevich MAP
Owner's Address: 104 Oak Street PARCUE1
Weston, AM 02493
Date of Inspection: December 11, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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:
✓ Passes
Conditionally Passes
eedTsurther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: December 16, 2003
J)
The system inspector shall subm 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
DER 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 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 5 Inspection Form 6/15/2000 page 1
t C
• Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 274 Mistic Drive
Marston Mills. MA
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.
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
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 274 Mistic Drive
Marstons Mills. AM
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
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.
_ 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 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: 274 Mistic Drive
Marstons Mills, MA
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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.
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
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
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 274 Mistic Drive
Marston Mills. AM
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
Check if the following have been done: You must indicate`yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ 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(3)(b)].
5
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 274 Mistic Drive
Marston Mills, MA
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a
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)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): end
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): 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:
Unknown
Were sewage odors detected when arriving at the site(yes or no): 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: 274 Mistic Drive
Marston Mills, MA
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
BUILDING SEWER(locate on site plan)
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: ✓ (locate on site plan)
Depth below grade: 20"
Material of construction: ✓ concrete _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: 1600 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (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
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Mistic Drive
Marston Mills, MA
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
TIGHT or HOLDING TANK: None (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: Qallons
Design Flow: gallons/day
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: None if resent must be opened) locate on site plan)
( P P )( P )
Depth of liquid level above outlet invert:
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.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
a.
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Mistic Drive
Marstons Mills. AM
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 gal.)
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 ofsoil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
The original pit 01)was dry. The bottom to grade was 8.0'. The cover was to grade. The newer pit(#2)was dry. The scum line
was approximately Y up from the bottom. The cover was to grade. There did not appear to be any signs of failure.
CESSPOOLS: None (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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: None (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.):
9
e
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Mistic Drive
Marston Mills, MA
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
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.
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Page 11 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Mistic Drive
Marston Mills. MA
Owner: Eleanor Panasevich
Date of Inspection: December 11, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40 +/- 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: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
_Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
40'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
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COMMONWEALTH OF MASSACHUSETTS `
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS `
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
FEB 13 2002 t
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPO§AL SYSTEM FORM J
PART A'
CERTIFICATION
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648
Owner's Name: KINGSLEY h
Owner's Address: 22 HARWICH PINES HARWICH MA 02645 - "9
Date of Inspection: 1/14/02
Name of Inspector: (please print) JOHN GRACI }.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA..02536r, '
- P
Telephone Number: 508-564-6813 FAX 508-564-7270
N
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at,this,address and that the information reported below is 1,�;
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 sewaged> posal.systems.I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR.15.000).�,The'system:
X Passes s; r
_ Conditionally ses
Needs F valuation by the Local Approving Authority
Fails a
Date: 1/14/02
Inspector's Signature:
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„a r
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)with'ti
30 days of completing this inspection. If the system is a shared system or has`a design flow of 10,000 gpd or greater,
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should bey
sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. `{
- 4
Notes and Comments F .'
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING1VERY TWO YEARS TO PROLONG.THE ;
SYSTEM'S USEFUL LIFE.
****This report only describes;condltions at the time of inspection and.,under the conditions of use at that time.Thin„ ,
inspection does not address how the system will perform in the future under the same or different conditions of use: ,'
14,a.a
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Title 5 InmPrtinn Fnrm All 5/lf1f n
Page 2 of 11 ° ,
a
OFFICIAL INSPECTION FORM—NOT FORWVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A:Y� {
CERTIFICATION(continued)
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648
Owner: KINGSLEY $'
Date of Inspection: 1/14/02 f
Inspection Summary: Check A B,C,D or E/ALWAYS complete all of.Section D
P ry� �
A. System Passes: :01
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG TH417
M
SYSTEM'S USEFUL LIFE. U
�h
B. System Conditionally Passes: °
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The sysA "
upon completion of the replacement or.repair,as approved by the Board of'Health,will pass. � '
�A T
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain �-J!° '
f yt�`
M1 f�H
n/a The septic tank is metal and over 20 years old*or the septic tank(W, ether.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; ,
wit.
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 indicatq
that the tank is less than 20 years old is available. " r.
ND explain: n/a
P ; ,4
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructd� a
pipes)or due to a broken,settled''`or uneven distribution box.System)vill pass inspection if(with approval of Board of .
Health):
_ broken pipe(s)are replaced
f Ct
obstruction is removed x
_ distribution box is leveled or replacedpF :{ r
1
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 r`
za. ,sE
ND explain: n/a t `
f
i
e
Page 3 of 1 l
OFFICIAL INSPECTION FORM -NOT FOR°VOLUNTARY ASSESSMENTS ^
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION'{continued)
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648
Owner: KINGSLEY
Date of Inspection: 1/14/02
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.
R
1. System will pass unless Board of Health.determines in accoedance;with 310 CMR 15.303(1)(b)that the system.li
not functioning in a manner which will protect public healtlt;'safety and the environment: t
r
..c k,V
_ Cesspool or privy is within 50 feet of a surface water r
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland,or a salt marsh
• _ Ta i'e + .
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that thef
system is functioning in a manner that protects the Dublic health,safety and environment: .11
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water '; n
supply or tributary to a surfaee water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
3
- The system has a septic-tank and SAS and the SAS is within 50 feet of a private water supply well. f
_ 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 4 .. }
supply well".Method used to determine distance n/a }
"This system passes if the well water analysis,performed at a D,EP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of arampzll
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: ¢ '
g
ri
3. Other: `}
xs
{
n/a
a K4
f�.
Yy'1 Y
1
f�
t
ti� .lit
Page 4 of 11
0 :
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS K
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
� r;
PART A � ,: a a.�•�,
CERTIFICATION(continued) ,
a..�
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648
Owner: KINGSLEY
Date of Inspection: 1/14/02
f
D. System Failure Criteria applicable to all systems:
You mist indicate"yes"or"no"to each of the following for alLinspections;
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged ,, ;
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or gged SAS or cesspool �t
X Liquid depth in cesspool is less than 6"below invert or available volume is less t '/Z day flow 3 s
X Required pumping more than 4 times in the last year NOT due,to`clogged or o tructed pipe(s).Number of times ' � .
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high groutld:;water a ation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water pply or tributary to a surface water supply' 4:
X Any portion of a cesspool.or privy is within a Zone I of a public 1.
X Any portion of a cesspool or privy is within 50 feet /aaater supply well. A� `
_ X Any portion of a cesspool or privy is less than 100 fr than 50 feet from a private water supply well with- y
no acceptable water quality analysis. [This system well water analysis,performed at a DEPcertified laboratory,for coliform bacteria and nic coin ounds indicates that the well is free ''from pollution from that facility and the presenia nitrogen and nitrate nitrogen is equal to or {r s
less than 5 ppm,provided that no other failur criteria are triggered.A copy of the analysis must be
P
attached to this form.]
1 .
(Yes/No)The system fails. I have determine that one or more of the above failure criteria exist as described m 310 t�
,
CMR 15.303,therefore the system fails.The system er should contact the Board of Health to determine what will be
necessary to correct the failure.
n
E. Large Systems: :
To be considered a large system the sys m must serve a facility with a design now of 10,000 gpd to 15,000 gpd. s
You must indicate either"yes"or"no t each of the following: '•.
The followingcriteria apply to large stems in addition to the criteria above) 7
yes no ,
X the system is within 400 eet of a surface drinking water supply,,.
w k
X the system is within 0 feet of a tributary to a surface drinking water supply
X the system is Ioca d in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped w»
Zone II of a p lic water supply well
t
If you ha v answered"yes"to any question in Section E the.system is considered a significant threat,or answered,
"yes"in Sectio above the large system hay failed.The owner or operator of any large system considered a significant threat"
under Section E or failed under Section I�shall upgrade the system[n aCcortiance with 310 CMCt 15.304.The system dwnera '
p>� Y Y i r, a
should contact the appropriate regional office of the Department. "�
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648 .
Owner: KINGSLEY # _ z
Date of Inspection: 1/14/02
Check if the following have been done.You must indicate"yes"or fas to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant',or Board of Health �i u
_ 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?
r
X Were as built plans of the system obtained and examined?(If they not available note as N/A)
z.
X _ Was the facility or dwelling inspected for signs of sewage back up.? �>a
X _ Was the site inspected for signs of break out? a `
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
ry
F.t
fir. z "wa�
The size and location of the Soil Absorption System(SAS)on the site has been determined based on: h*
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 s
unacceptable)[310 CMR 15.302(3)(b)] i
�r
k.
p
m .
-
*Y,_
.K
fi rx
w
r
kt
Page 6 of 11
g i
tb� i MiiiJ3�
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i h
PART C n
SYSTEM INFORMATION
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648
Owner: KINGSLEY is
Date of Inspection: 1/14/02
3
FLOW CONDITIONS '
RESIDENTIAL
of bedrooms(actual): 3 .
Number of bedrooms(design):3 Number ( )( gn
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 ' Y a
Number of current residents:2 i
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 o '�
Water meter readings, if available(last 2 years usage(gpd)): n/a 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/agpd .,
3
Basis of design flow(seats/persons/sgft,etc.): n/a x `
Grease trap present(yes or no):
: NO
f
t
Industrial waste holding tank present(yes or no): NO r,.r
Non-sanitary waste discharged to the Title 5 system(yes or no). NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/as ;
OTHER(describe): n/a '*'
GENERAL INFORMATIONS;',
Pumping Records a t
Source of information: n/a
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 r A,
Reason for pumping: n/a '
TYPE OF SYSTEM '�A
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
rti '
_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) h
_Tight tank Attach a copy ofthe DEP approval ;° .
Other(describe): n/a ;" '
4p; H
Approximate age of all components,date installed(if known)and source of information:
ORIGINAL-30 YEARS BY OWNER
Were sewage odors detected when arriving at the site(yes or no):NO.k,Y'
h
A
Page 7 of l 1
Y`
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS : r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' „
� 4 ,
PART C;
SYSTEM INFORMATION(continued)
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648 ' , t
Owner: KINGSLEY
4
Date of Inspection: 1/14/02 `
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _40 PVC Xother(explain) ORANGEBURG
Distance from private water supply well or suction line: n/a ft' '
Comments(on condition of joints,venting,evidence of leakage,etc) l
TOWN WATER
SEPTIC TANK: X(locate on site plan)
%i
Depth below grade: 12" i
Material of construction:Xconcrete_metal_fiberglass polyethylen01,9 ther(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 81 611 H 51 711 W 4.10
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness: 1"
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 n/a fig`
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related 5 A ..
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY:SOUND AND FUNCTIONING PROPERLT ,
RECOMMEND PUMPING EVER'TWO YEARS TO PROLON(;THE SYSTEM'S USEFUL LIFE. $r
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a 2
Material of construction:_concrete metal_fiberglass polyethylene, other(explain): n/a
Dimensions:n/a
Scum thickness: n/a s '
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 h
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related� r
y $�xar
to outlet invert,evidence of leakage,etc:):'' >,
n/a
i
E x
F,h
Page 8 of 1 I �
OFFICIAL INSPEC
TION FORM—NOT FORWOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :;;
PART C { F
SYSTEM INFORMATION(continued)
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648'
Owner: KINGSLEY
Date.of Inspection: 1/14/02
¢ray
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a z
Material of construction: concrete metal fiberglass_polyethylene other(explain): n/a t:�
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/days
Alarm present(yes or no): N/A
r no .NO
Alarm in working order es o
Alarm level: N/A A g (y )'
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.): s
n/a �
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) '
Depth of liquid level above ou
tlet invert: n/a
Comments(note if box is level and distribution to outlets equal,any eyjdence.of solids carryover,any evidence of leakage into Jl ,
or out of box,etc.): t `
NONE , A4,
' F iiT
PUMP CHAMBER:_(locate on site plan) tv l
Ibt
Y
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
u
I �
t..
E .
i
i
v:
M
I
i Page 9 of I 1
4.
OFFICIAL INSPECTION FORM—NOT FORYOLUNTARY ASSESSMENTS s �g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648
Owner: KINGSLEY
Date of Inspection: 1/14/02 ai3'
{
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) f $P
If SAS not located explain why:
n/a
. f 5
T i
YPe
1000 GAL 6'X 6' leaching pits, number 2 '
n/a leaching chambers, number: n/a _
leaching galleries number . n/a
n/a g 9 >
n/a leaching trenches, number,:length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
innovative/alternative system
n/a ` }
Type/name of technology,. n/a
F
r
N
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc) kk
LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.BOTH PITS WERE EMPTY' Y 5
AND THE NEW PIT HAS NOT HAD MORE THAN 1' OF WATER IN IT. BOTTOM AT 9' • .
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 z
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 Y
Dimensions:n/a ��
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure,level of nding,condition of vegetation,etc.):
n/a
q5,: <'�?
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION(continued)
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648 t
Owner: KINGSLEY
T 47.ih
ny�
Date of Inspection: 1/14/02
SKETCH OF SEWAGE DISPOSAL SYSTEM k'`
r 0
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. >=
O
r
n �
i a
•, e `�',. �ter;
ML
�W
t�
1
5
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t o
Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM T
PART C: ' r0.
;
SYSTEM INFORMATION.(continued) =t
p_
Property Address: 274 MYSTIC DR MARSTONS MILLS,MA 02648.
Owner: KINGSLEY "
4.
Date of Inspection: 1/14/02 tea:
SITE EXAM
Slope ;>
r
_Surface water
Check cellar
Shallow wells t '
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water.elevation: s
NO_ Obtained from system design plans on record-If checked,„date of design plan reviewed: n/a
YES Observed site(abutting property/observation.hole within 10,'feet of SAS) x
NO Checked with local Board of Health-explain: n/a 2R
NO Checked with local excavators,,installers-(attach documentation)
YES Accessed USGSdaiabase-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.NOW WATER ENCOUNTERED ANDpUSGS MAPS AND CHARTS
C— r n
a
a�
4
t
h
s �
DATE:!1z23199
PROPERTY ADDRESS:--2.74 Mystic Drive_
Marstons Mills Mass .
------------------------
02648
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following;
1 . 1-1000 gallon septic tank.
2 . 2-1000 gallonprecast leaching pits .
Based on my Inspection, I certify the following conditions:
3 . This is a title five septic system . ( 78 Code )
4 . The septic system is -in proper working Order
at the present time:
SIGNATURE:,f Company: JoseTh_P. Macomber_& Son , Inc .
Address; Box 66
Centerville , Ma__02632-0066
Phone:-----508-775-3338
----------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARY
�
1 ,
JOSEPH P. MACOMBER & SON, INC.
� FO
Tan ks-Cesspools-Leachfleldso�e� j9
Town Se a Pumed &Connne�ct ons �, �°4ls�, `99
-P.O. Box 66 Centerville, MA 02632.0066
775.3338 775.6412 4 z..
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF-ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5600
TRUDY COXE
Set:aetary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropedyAdd►ess: 274 Mystic Drive N„neofownwMichael Pusateri
M a r s t o n s M i $ $ 02648 Address of owner:
Date of kupection: }}/ 2�/ �� .
Name of Inspector:(Please Print) Joseph P.Macomber J r.
I am a DEP oved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
compenyNan": J.rmacomber & Son Inc .
�MangAddress: Box Centerville,Mass _a 2632
Telephone Number: 508 7 7 5 3 3 3 8
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 Inspection. The inspection was performed based on my training and experience In the proper function and
maintenance of on-site sewage disposal systems. The system:
yPassesf
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails J
Inspector's Signature: - r Date: -X
The System Inspector hall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
shall submit the report to the appropriate regional office of the Department oK-nvironmerttal Protectlon. The original should'be sent toVW
system owner and copies sent to the buyer, if applicable,and the approving authority. .
NOTES AND COMMENTS
,
revised 9/2/98 Page Iof11
�, Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTiON FORM
PART A
CERTIFICATION(continued)
Prop"Addre": 274 Mystic Drive Marstons Mills ,Mass .
Owner: Michael P88abeti
Date of Inspection: 1 1/2 3/9 9
WSPECTION SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES: .
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
A/, 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.
Indicate yes,no,or not determined(Y,N,or NO). Describe basis of determination in all Instances. If "not determined", explain why not.
A2 The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection; or
the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial Infiltration or exfiltration, or tank
failure is imminent. The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as
approved by the Board of Health.
�fXJ� riewage backup or breakout or high static wet r level observed in the istribution box s due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ - The system required pumpMg•more than fourtfines•ayeardue to broken or obstructed pipe(s). The aystem wiif-va
inspection if(with approval of the Board of Health): - --
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 274 Mystic Drive Marstons Mills ,Mass .
Owner: Michael Pusateri
Date of Inspection: 11/2 3/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_A Conditions exist which require further evaluation by the Board of Health in order to determine If the system is failing to protect the
public health, safety and 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,YALL.PRCMECT THE PUBLIC i MTRAND SAFETY AND THE E LMONMENL
A Cesspool or privy is within 60 feet of surface water
Cesspool or privy is within 60 test 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 AND SAFETY AND THE ENVIRONMENT:
4&3 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 soil absorption system and the SAS Is within a tone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 60 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the
well is free from pollution from that facility and the pressr)ce of tammonia nitrogen and nitrate nitrogen Is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).-
3) OTHER
4117
revised 9/2/98 Pa&e3ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 274 Mystic Drive Marstons Mills ,Mass .
Owner: Michael Pusateri
Date of Inspection:11/2 3/9 9
D. SYSTEM FAILS:
You must Indicate either "Yes" or"No" to each of the following:
i 1 have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this
determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes N
Backup of•sewage into feciRty"er-•eYetem component-due%to an overloaded ormbggedSiAS-orceaspod. =�•---��-=
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
/skL_ r e; Static liquid levr I in1he diskibUtii box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in aee9peel}y7; is less than 6" below Invert or available volume Is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed ptpe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater elevation.
Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy Is-within a Zone I of a public well.
Any portion of a cesspool or privy Is within 60 feet of a private water supply well.
Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
»coliform bacteria, volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
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:
ADI The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No/
L/ the system Is within 400 feet of s surface drinking water supply
_ the system-ls•witWn 200 1eetof+V413-utary4"4u w+tar•supply•
the system is located to a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further Infor,Ination.
revised 9/2/98 Page 4of11
I
i
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 274 Mystic Drive Ma•rstons MIlls ,Mass .
Owner: Michael Pusateri
Date of Inspection:1 1/23/99
Check if the following have been done:You must indicate either"Yes' or "No" as to each of the following:
Yes No
Pumping information was provided by the owner,occupant, or Board of Health.
f1 -None of the system cornponants kame:bwn system hasbaaoasceiaiagwsasai flow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,4'MCluding the Soil Absorption System,have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
The facility owner-(and.^^ .ts,1f difteraat frzrn o war)Avsre.prautdad with Infauaatiomon the Ors a• n*aR"^,.j Qf
SubSurface Disposal Systems.
ti
1
i
i
revised 9/2/98 Page 5of11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 274 Mystic Drive Marstons Mills ,Mass .
Owner: Michael Pusateri
Dace of kupection: 11/2 3/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1-149 g.p.d./bedroo .
Number of bedrooms(design : Number of bedrooms(actuaq:_j
Total DESIGN flow
Number of current residents:20
Garbage grinder(yes or no):_
Laundry(separate system) s o no :_, If yes, separ4asInspaction.required --.
Laundry system inspected a or no)
Seasonal use(yes or no):AE
Water motor readings,If av able (last two year's usage(gpd):
Sump Pump(yes or no)
Last date of occupancy..1
S�J�I'VirG'�Gv' �� �L yOIL°fc�vT
CO M M ER CIA L/INDUSTRIAL:
Type of establishment: ,t�JP
Design flow: ,V aad ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present:(yes or no)A24-
Non-sanitary waste discharged to the Title 5 system:(yes r no)AO -
Water motor readings,if available:
Last date of occupancy: Abof
OTHER:(Describe) AO
Last date of occupancy:
GENERAL INFORMATION
PUMPING�T D��;our 9_of information:
System pumped as p/af n of inspection:(yes or no)10
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF YSTEM
Septic tank/diaoRmtien-bmclsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc Attach copy of up to date�operstlon and maintenance contract
Tight Tank 014 Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date InstaNed4if known)-and source of4aformstion: -
Sewage odors detected whowerriving at the site: (yes or no),:±4
revised 9/2/98 Page 6of11
• r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
Property Address: 274 Mystic Drive Marstons Mills ,Mass .
owner: Michael Pusateri
Data of Inspection:11/2 3/9 9
BUILDING SEWER:
(Locate on site plan)
Depth below grader
Material of construction:Zast Iron Z0 PVC4eother(explain)
Distance from Brivate water supply well or suction line If
Diameter
Comments:(condition of joints, venting,evidence of feak"a,-etc.) - —
Joints appear tight No vidPnrP of 1pakngP
s -anted through the h-ou-se *eat
SEPInC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concreted/ motaIA44Fiberglass AIRPolyethyleno,AAother(explaln)
If tank is (natal, list age jjZ Js.ag�ey.coo9nfirmed by Certificate of Compliance Yes/No)
y i(O i/0'
Dimensions: li I.r / VC
/Ztt'Sludge depth: dL__
Distance from top of Judge to bottom of outlet tee orbaff(e:2"tz
Scum thickness:
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet or baft�
How dimensions were determined:
Comments:
(recommendation for pumpin condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structural-integrity,
evidence of leakage, etc.) ulnp '-tank°:ever.y 2-3 ,years,,Iialev & outlet
*P ps a r P i n 1! ar`P T i nri_d 1 eu6i 8t Gut'l6t iSVart 3S fif;`�—
,
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction;#AconcretaN�netal/Fiberglas"/APolyethylenoA_*ther(explain)
Dimensions:
Scum thickness: MR
Distance from top of scum to top of outlet tee or baffle: /mow
Distance from bottom of scum to bottom of outlet tee or baffler
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet toes or baffles,depth of liquid level In relation to outlet invert,structural integrity,
evidence of leakage, etc.)
Grease trap is not present .
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM INFORMATION(oor"od)
Property Address: 274 Mystic Drive Matstons Mills ,Mass .
Ownw: Machael Pusateri
Date of kupection:1 1/2 3/9 9
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade:AM
Material of construction:WAconcfetoWAmetaW_AFlberglassjf Polyethylene Ather(explaln)
AN
Dimensions: Nlf
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level:— Alarm In working order:Yes4&VNo&M
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
7ignt or nolding tanks area not present ,
DISTRIBUTION BOX:/�Vt
(locate on site plan)
Depth of liquid level above outlet Invert:
Comments:
(note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — -Distribution hnx i a not pre4ent
��99 G
PUMP CHAMBER:,�� ,
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)�I
Comments:
(note condition of pump chamber,condition of pumps and,appurtenances,etc.)
—Pump chamber is not present _
t
revised 9/2/98 Page 8orn
r I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Address: 274 Mystic Drive Marstois Mills Mass .
owns.: Michael Pusateri
Date of Inspection:11/23/99
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan, if possible;excavation not required,location may be approximated by non-Intrusive methods)
If not located, explain:
Type:
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number
Alternative system: n
Name of Technology: G�
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.)
Loamy sand to medium fine sand No signs of hydrniilir
f i 1 iira nr nnndi ngo Cni 1 0 pro rl �jTA-a-Atatj on i6 R6r mml
CESSPOOLS: G
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: AN
Depth of scum layer:
Dimensions of cesspool: AN
Materials of construction:
Indication of groundwater: AW
inflow(cesspool must be pumped as part of Inspection)
esspoo s are not present .
Comments:
(note condition of soil, signs of hydraulic failure,level of pending,condition ofrvegetation, etc.)
Cesspools are not present
PRIVY:
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids: AhV
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Privy is not present
revised 9/2/98 Page 9of11
SU&3URFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
ART C
SYSTEM INFOPJ4Ano#y(oon ljod)
Pro�.nyAaa.�: 274 Mystic Drive Karstons Mills ,Mass .
owr,«, Michael Pusateri
D.v or In`°"`ia" 1 1/2 3/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM: .
Include ties to it Will two permanent reference landmarks or benchmsrks
locate ell wills wlWn 100'jLoceu where public wetar supplY comes Into house)
he
►
revised 9/2/98 Y�ce loof 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 274 Mistic Drive Marstons Mills ,Mass .
owner: Michael Pusateri
Data of trupection:11/2 3/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Collar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water table contours map .
Gahrety & Miller
12/16/94
revised 9/2/98 Page 11of11
+ a•rrnr+r a—n .•+�— .•.rranr•n.n. ••'Rr T1+.t7srxre*Rr.7r•►1'er►t�wTRwn fn�t`Y f�'7r►�rtllT T7rTTT�.4+TT•.tr.r•
TOWN OF Barnstable WARD OF HEALTH -;
SUIISUNFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D•- CEII'PIFICATION
^•rr•e•r•.._:..— •r.=.-rnmr.+n'rtrrtrnaesrran�r►rrt•trtunrtwwb—`r�+rwwre'wr7 son. v*+rrr•rr-ter—..�
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET. ADDRES$ 274 Mistic Drive Marstons Mills ,Mass .
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber & Se'1S 'Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632.
Street Town or City state LlP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
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 ,
Systeui PASSED t
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh 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 con acted has found that the system fails to
Protect the j)ublic health and the environment in accordance with Title
6 , 310 CMR 16 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
( whezopa of tl;is ttfication must be provided to the OWNER, the BUYER
pplicable and the 130ARD OF HEAL111.
* If the inspection FAILED, the owner or*"'operator shall u d
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 . 306 . '
partd .doc
I• � 4 C���i1-�. 4
r /�o /
y .
BORTOLOTTI CONSTRUCTION, INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
509-771-9399 508428-8926 FAX. 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:
Date of Inspection:62 Inspector's Name:
owpees Name and Ad ess:
4 J
CERTIFICATION STAT .MENT•
I certify that I have personally inspected the sewage disposal system at this address and that the'.informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was!per-
formed b on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
r Passes
I Conditionally Passes
NeedsFurther Ev ti y e Local Aproving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of.completing this inspection. If the system is a shared system or has a designAow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the.appropriate regional
office of the..Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer;if applicable and the approving authority.
,f
INSPECTION S IMMARY*
A)SYS PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
i
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or
? exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water.level'observed in the distribution box is due
to broken or obstructed pipes)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- 1 -
SbA
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
1 PART A ,
" A.
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health): ,
Broken pipe(s)are replaced
Obstruction is removed
6-FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation The Board of Health in order to determine if
by
eq , .
the system is failing to protect the public health,safety and the environment.
"1)SYSTEM WILL•PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
`,SYSTEM IS NOT FUNCTIONING°IN A,MANNER WHICH WILL PROTECT THE,
PUBLIC HEALTH AND SAFETY AND•THE ENVIRONMENT:
.Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.'
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE`SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND TH_ E
ENVIRONMENT:.. ;
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply. ^'
The system has a septic tank and soil absorption system and is with a Zone I of a publio
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private"
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free"from pollution from
iI the facility and the presence of ammonia nitrogen and nitrate nitrogen`is equal to;or less
1 ` 'than 5 ppm
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool: `'
,w Static liquid level in the distribution box above outlet invert due to•an overloaded'or slog=
i., ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert.or„available;volumo is less than 1/2 ;
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
s' pipe(s). Number of times pumped
2-
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CEW IFICATION (continucd)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is-a'slgnificant.
;threat to public health and safety and the environment because one or more of the following
'conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply.
The system is located in a nitrogen sensitive area Interim Wellhea&Protection Alva`
(IWPA)or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the locale' ''
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check Pe following have been done:
I/ Pumping information was requested of the owner,occupant,and Board of Health.
-None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
✓As-built plans have been obtained and examined. Note if they are not available with N/A.
,- a facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or.industrial waste flow.
The site was inspected for signs of breakout.
>� t.All system components,excluding the Soil Absorption System,have been located on site.
=The septic tank manholes were uncovered,opened,and the interior-of the septic tank was in=
•- petted for,condition of baffles or tees,material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
Iyy� The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
l_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
t/ The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIALt
Design Flow:,,L2M_gallons Number of Bedrooms: 3 Nw be of Current Residents:_
Garbage Grinder: Laundry Connected To System: Seasonal Use: !l�
Water Meter••Read' gs,if ailable:
Last Date of OccuPancy'_ZZ&de Z -
Type of Establishment:
Design Flow: ¢illons/day Grease Trap Present: (yes or no).
Industrial Waste Holding Tank Present:
Non-Sanitary.Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of inform tion:!�C!/ C.r�.� 19t
System Pumped as part of inspection: �/ if yes,volume pumped: - ; p dlons
Reason for pumping:
TYPE F SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
AJ?VROXUdATE AGE of all co nents,date installe (if known)and source of information:'
�. . Sewage odors detedled when arriving 6t the site: ,('d
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: !/
Depth below grade: Material of Constriction: concrete metal FRP_Other
(explain) I
Dimisions: -6 A &'X 5-" Sludge Depth:_ J�' Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom.of outlet tee or baffle: P
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relatio 0 outlet invert, structural integrity evidence of leakage,etc.) d
6�4
GREASE TRAP: A-)
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments:'*(recommendation for pumping,condition of inlet and outlet tees or baDlei,depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage. etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain)
Dimensions: Capacity; gallons Design Flo« gallons/day
Alarm Level:
Comments: (condition of inlet tee, condition of alann and float switclues, etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments::(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into
or out of box,etc.)
PUMP CHAMBER:
Pump is in working or er.
Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.)
5
Rev : A: A �< ;.
'SUBSURFACE SEWAGEDISPO5ALSYSTEM INSPECTION FORM
PART.0
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):,
i non-intrusive
on site Ian if possible;excavation not required,but may approximated(Locate be a o sled non intrusive
P Po eq Y pp by
methods) If not determined to be explain:
+present,ex pa
TYpe, ;
Leaching pits,number: 0? Leaching chambers, number: Leaching galleries,number: r.
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool, number:
Comore , :(not ndition of soil,signs of hydraulic failure level of ponding., ondition of a tation,
etc.)
CESSPOOLS:111L ,
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(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
i
PRIVY:
Materials of construction: K - Dimensions:
Depth of Solids:
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
-6-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all.wells within 100 Feet.
nI
1
Y�
t
DEPTH TO GROUNDWATER:
Depth to groundwater: g Feet ,- ®
Method ofDetermi Edon or ppro'oration: /�- /?1 Y)"le, �/�hr G<•S. �4 l"
-7-
sir''^"•, y ,� .. s
J. T WN OF BARNSTABLE
',I,
�� 1 ��I !�- �• SEWAGE #
VILLAGE M. ✓►n>>Is ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �Q /n� LL
LEACHING FACILITY: (type) 07 ' R 4 T ( K 6' (size) M
NO. OF BEDROOMS 3
BUILDER OR OWNER CAI
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 leachi facility) �+ Feet
Furnished by -rnSDu.T►Un F"G/
a�
O ;4�
(a
e
y� -
TOWN OF BARNSTABLE
Lv- ON � vl \ ' t �� 1� SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT a dl
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS } ,
BUILDER OR OWNER ` C- '
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
Furnished by
y
J
`' TOWN OF BARNSTABLE.
LG AT ON T SEWAGE #
VILLAGE ASSESSO IS MAP & LOT
3�YSPjP;S •NAME&PHONE NO. 1J7LO.►� � ��
SEPTIC TANK CAPACITY li0o0 . - ,tip�'.zeAZ
LEACHING FACILrrY: (type) . X7 (size) 10W l-L
NO.OF BEDROOMS
BUILDER O OWNER
4AZ
PERMTTDATE: 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
Furnished by
ITV
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- Preliminary plans and layouts by D.C.D.are for the use of their customers only.Any other use is strictly prohlbite '