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HomeMy WebLinkAbout0183 OLD MILL ROAD - Health 183 Old Mill Road Marstons Mills P A = 063 020 I � Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w. 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required)for Marstons Mills MA 02648 January 17, 2010 every page. Cityrrown 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: A. General Information When filling out (� forms on the J� / computer,use 1. Inspector: only the tab key to move Vour Darren M. Meyer cursor-co not Name of Inspector use the return key. n/a Company Name PO Box 981 Company Address East Sandwich MA 02537 City/Town State Zip Code 781-424-6748 S13920 Telephone Number License Number B. Certification 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,.,1.5.340-9f Title 5 (310 CMR 15.000). The system: ca ® Passes � 4 ❑ Conditionally Passes ❑ Falls w� n ❑ Needs Further Evaluation by the Local Approving Authority -77 l t — 11n)t&s"Signature Date The system inspector shall submit a c y of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of Cori o pleting 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. Lt5ins09/08 Ij d Title 5 Official Inspection Form:Subsurface S F Disposal ystem• age 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Old Mill Road Property Address Philip Kirby Owner Owner's Name information is ry Marstons Mills MA 02648 January 17 2010 required for , every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 183 Old Mill Road Property Address Philip Kirby Owner Owner's Name information required forts Marstons Mills MA 02648 January 17, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•09108 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 ;M 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Forth: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 �.� 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4(per Asses) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 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 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2008: 16 gpd 2009: 00 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Ind ustrial waste holding tank present. El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °°M s 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 183 Old Mill Road Property Address Philip Kirby Owner Owner's Name information is ry Marstons Mills MA 02648 January 17 2010 required for , every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed in 2003/system is approx. 6 years old. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): No signs of leakage. Septic Tank(locate on site plan): Depth below grade: 28" 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: typical 1,000G septic tank Sludge depth: 8" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is Marstons Mills MA 02648 January 17, 2010 required for every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2" 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 13" How were dimensions determined? Tapes and rods Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees look normal, liquid levels normal and equal to bottom of outlet pipe, no signs of hydraulic failure, soil normal,vegetation normal Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Old Mill Road Property Address Philip Kirby Owner Owner's Name information required forts Marstons Mills MA 02648 January 17, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert equal to outlet pipes Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears sound, no sign of solids carryover, no sign of hydraulic failure, soils normal, vegetation normal, box is 36" below grade w/pvc riser to within 12"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-50OG chambers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of.ponding, damp soil, condition of vegetation, etc.): Leaching is dry, no sign of hydraulic failure, no surficial ponding, soils normal, vegetation normal, bottom of chambers is apporx. 72" below grade. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form: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 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached.separately o � 2 / i I� J TtE 20� A • 3 = 9 F3-3 35ry A - N ; (00 y ' 41 6 I t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is MarstonS Millsrequired for MA 02648 January 17, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >14 feet below grade feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand Augered hole to 14ft below grade, did not encounter water. Bottom of leaching approx. 6 ft. below grade. System is not within adjusted groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Old Mill Road Property Address Philip Kirby Owner Owners Name information is required for Marstons Mills MA 02648 January 17, 2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF B STABLE s, SEWAGE# 003 2 31/ LOCATION VII,LAGE 'A '"""��h� ASSESSOR'S MAP &LOT G ^za a - INSTALLER'S NAME&PHONE NO. SEPTIC TANK.CAPACITY LEACHING FACILITY: (type) <^�a `O� �'� °' (size) NO.OF BEDROOMS y ' BUILDER OR OWNER (� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leac 'n faci ' ) Furnished by -?o 0 s VDate: Gi�,u tom`' r i�' � TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: Ccxr e So Sa Sea BUSINESS LOCATION: Q S l MAILING ADDRESS: Samy_ Mail To: Board of Health TELEPHONE NUMBER: 5d - IL{a 4�-69 Town of Barnstable CONTACTPERSON: 1 P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBE 7 )�f - (�1 Hyannis, MA 02601 TYPEOFBUSINESS: ��C; A C`� re Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO) This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS l v e V Commonwealth of Massachusetts 1�g ` Executive of Environmental AffairsDEP r G� Department of Environmental Protection - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: \�!; oc1� �^� �\ 1 c T s , �\s + k Address of Owner: (if different) s� � ��;.,, , , Date of Inspection: ct Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel: (508)4771420 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 - Passes --- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signature: Date: '�A- \`y`C� The system Inspector shall submit a copy of this inspection report to the Approving Authority 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 83 o Cz�- v,\, �\ 'Z& Owners : I�cv_L�� D ate of Inspection :- nspection : INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: Y\I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated",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 septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is 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 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner : Date of Inspection : C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: --• Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 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 SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water -•-- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE 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 within a Zone I of a public 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 wen,unless a well water analy- sis 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 notrogen is equal to or less than 5 pprK D)SYSTEM FAILS: -- I have determined that the system violates one or more of the following falure criteria as defined 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 cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool 3 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: %£;z� o i z m,\.�. V Owner: Date of Inspection.: D)SYS T E M FAI LS (continued) -- 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 over- loaded or clogged SAS or cesspool. -- Liquid depth in cesspool 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 pipe(s). number of times pumped --- Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. h• SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: O wner. Date of Inspection : E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design !`low of system is 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 foNowing 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 Wellhead Protection Area -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 compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. f S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The System does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components,excluding the Soil Absorption System, have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the Sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions,depth of liquid, depth of sludge, depth of scum. -•x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners 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 Property Address: r li�'s o k-s' Vy." Owner: c,.r.y�_� Date of Inspection: A kCkVt RESIDENTIAL: Design flow: —'S—�C> gallons Number of bedrooms o'er Number of current residents: c> Garbage grinder (yes or no) : Laundry connected to system (yes or no): c5 Seasonal use (yes or no) : tJo Water meter readings:,if available: N�ts, . Last date of occupancy STD COMMERCIAL/INDUSTRIAL : Type of establishment: Design flow : callonslday 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 : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection1yes or no):..... ..... if yes, volume pomped: .................... gallons Reasonfor pumping :............................................................................................................ f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: t%---, o 9-6 , Owner: , cam Date of inspection: 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) - Other (explain).. T�c...'�.i' .... .!gip. .. - �.�..�.. APPROXIMATE AGE of all components,date installed (if known)and source of information .....�Q ..... ...... �. ....................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).............. 'SEPTIC TANK : ;(locate on site plan) Depth below grade: .. Material of construction: ...'gconcrete ......... metal ........ FRP........ other(explain) . ................................................................................................................................................. Dimensions: 75'� x.S Sludge depth:..C?.``..... Distance from top of sludge to bottom of outlet tee or baffle:.......3y................ Scum thickness :..... `!......... Distance from top of scum to top of outlet tee or baffle: ........1.Gz.......................... Distance from bottom of scum to bottom of outlet tee or baffle :.... ................ Comments : (recommendation for pumping ,condition of inlet and outlet tees or baffles, depth of liquid level in relationp outlet invert,structural inte rity,evidence of leakage,etc.)............ �..�..�r. ..�1.►�U:r... Wiz?.... , L V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: C6,t Owner: ��� Date of inspection: GREASE TRAP : (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... D imensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... affle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc.)........................ .........:...................................................................................................................................... ................................................................................................................................................... TIGHT OR HOLDINGi TANKS:..... (locate on site plan) Depth below grade:................ Material of construction:........concrete........metal.........FRP..........other (explain) .:............................................................................................................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee,condition of alarm and float switches, etc.) ...............................................................................:................................................................. ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: t S,-:n-, O VZ� 4V\,`\ 4 0 wner: taC-�- � Date of inspection: q \ (� Z DISTRIBUTION BOX:..►�,p (locate on site plan) Depth of liquid level above outlet invert:................... Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into orout of box, etc.).................................................................................................................. ................................................................................................................................................ ................................................................................................................................................. PUMP CHAMBER:....Q.0.. (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... .................................................................................................................................................. ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):.. ..... (locate on site plan, if possible; excavation not required,but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ .................................................. .........1..................................................................................... Type: 1a.. leaching pits, number: .A.. .kpk. leaching chambers, number:........ leaching galleries,number:........... leaching trenches,number , length:..................... leaching fields, number,dimensions:................... overflow cesspool, number:.......... Comments: (note ndition of soil, signs of by aulic failure,level of ponding, o f vegeta CrP l �� .r• . . ... .. ✓f'o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD PAR T C SYSTEM INFORMATION (continued) Property address: vyN• &4 , Owner: Date of inspection: CESSPOOLS:.... ] (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................... ................................................................................................................................................. PR IVY : ... (locate on t e site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.). ................................................................................................................................................ ................................................................................................................................................ r e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a 12—d , Owner. Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' ( z DEPTH TO GROUNDWATER: Depth to groundwater: ... .feet Method of deterrr*ation or approximative: ............................................................................................ ................................................................................................................................................ ................................................................................................................................................. —,-_ C01L\t0\'\i'E.%LTH OF MASSACHUSETTS £ _ EXECUTIVE OFFICE OF EN-MON-11ENTAL AFF_AJR-S, DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE n'L=R STREE'. BOSTON INL4 0210t i6I:i 242-550v TRIDY COL Secreta-y ARGEO PALL.CELLtiCCI DAVID B STP.-'HS Governor COtnt7ilS570i1e7 SUBSURFACE SEWAGE DISPOSAL SYSTBN WSPECTION FORM PART'A CERTI FWAT10N a Property Address:18 3 Old. Mill Rd.. Name of owner Helen & Fred. Ackley M ar s t o n s Mills Address of Owner: Date of Inspection: .2-1 yi-0-0 Name of inspector:( e Print)Wm. E. Robinson S r. 1 arrn a DEP approved s ern inspector to Section 15.340 of Title S(310 CMR 15.000) Company Name:: W1I ? E . Robinson Septic Service MeiTingAddress: PO Box 1089, Centerville MA Telephone Number: CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as Hof the time of inspection. The inspection was performed based on my training and-experience in the proper function and maintenance of an-site se e disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation BY the Local Approving Authority _ Fails Inspector's Signature: lell'v l�. Date: The System Inspector shall 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 of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer.if applicable. and the approving authority. NOTES AND COMMENTS J 4"! 2000 rev_ised Page IorU � M C: -•Alec o^RecN-cied Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM 611SPECTION FORM i. PART A CERTtRCATION feon6nued) Nop"Address:183 Old Mill Rd.. , Marstons Mills ate: Ackley Date of Inspection: INSPECTION SUMMARY: Cheek AO, B, C, or D: A. Sy 4A PASSES: 1 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. S TEM CONDITIONALLY PASSES: ne'or more system components as described in the "'Conditional Pass"section need to be replaced or repaired. The system,upon mpletion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes no, 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,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. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if Iwith approval of the Board of Health). broken pipe(s) are 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 pipets). The system will pass inspection if Iwith approval of the Board of Health): broken pipets)are replaced obstruction is removed yev;se 5/2/58 Page 2orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prop"Address:183 Old. Mill Rd.. , Marstons Mills Owner: Ackley V Date of Inspection: C. )RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: itions exist which require further evaluation by the Board of Health in order to determine if the system is tailing to protect the c health, safety and the environment. 1TEIM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(11(b)THAT THE SYSTEM OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FU CTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 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 then 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) THER Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddvess:183 Old. Mill Rd.. , Marstons Mills owner: Ackley Date of Inspecton: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct,the faiiure. Yes N Backup of sewage into facility-or system component due to an overloaded orebgged 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 112 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 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. LARG SYSTEM FAILS: You must i idicate either "Yes' or "No' to each of the following: T ie following criteria apply to large systems in addition to the criteria above: T ie 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 ealth and safety and the environment because one or more of the following conditions exist: 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) The own 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 he Department for further information. rev-sec PaRr4orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 183 Old, Mill Rd.. , Marstons Mills Owne*:A C k l e y Dace of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes Nc. Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and'the system has been recehAriq normal flow rates during that period. Large volumes of water have not been introduced into the system'recently or as part of this / inspection. v _ 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, excluding 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 on the site has been determined based on: V _ 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— U Y The facility owner (and occupants,if different from owner) were provided with information on the propermaintenanrA-0f SubSurface Disposal Systems. Yeti Se-6 G/ 2/9E rev:.se-6 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION -top"Address: 183 Old, Mill Rd.. , Marstons Mills owner: ACkle. Date of Inspection: rJ> FLOW CONDITIONS RESIDENTIAL: Design flow: ::I G 0 g.p.d.lbedroom. Number of bedrooms (design): Number of bedrooms (actual) Total DESIGN flow36 o Number of current residents110 Garbage grinder lyes or no): Laundry Iseparate system) (yes or noj- ; If yes, separate inspection required Laundry system inspected lye or no) Seasonal use (yes or no): /z Water meter readings, if available (last two year's usage (gpd): 1999 57, 000 gal Sump Pump(yes or no): A6 1998 38, 000 gal. Last date of occupancy:mt-&-el COMMERCIAUINDUSTRIAL: Type of stablishment: Design fl w: god ( Based on 15.203) Basis of d sign flow Grease tr present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanit ry waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: Last da of occupancy: OTH -(Describe) Last da a of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pump as part of inspection: (yes or no)�i p If yes, volume pumped: gallons Reason for pumping: TYPE 0V YSTEM Septic tankidistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records;if any) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: yz Sewage odors detected when arriving at the site: (yes or no) (� -ev-- se6 G%G/ �� Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropenyAddress: 183 Old. Mill 11d.. , Marstons Mills Owner: Ackley Date of Inspection: BUIL ING SEWER: (Local on site plan) Depth low grade:_ Materia of construction:_cast iron_40 PVC_ other(explain) Dista a from private water supply well or suction line Diem ter Co ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ llocate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) b yf Dimensions: 'C Z. °` g Z Sludge depth: ;3 Distance from top of sludq%to bottom of outlet tee or baffl Scum thickness: )"3 ,l Distance from top of scum to top of outlet tee or baffle: T' , Distance from bottom of scum to bottom of outlet tee or baffle:� How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet ancL outlet tt or baffles, depth of liquid level in relation t outlet invert, strr tur tegrity, evidence of leakage, etc.) `O f1-� �.s � / •" h t>��G� A7d�!/�� $ Al -rA.L:p 7-► GR SE TRAP: (local on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dime ions: Scu thickness: Dist nce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: D e of last pumping: Co ments: (rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi ence of leakage, etc.) r e'% CCU J/2/J C Page 7 of 11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION Icondrwed) ►rope'rtY Address: 183 Old. Mill "d.. , Marstons Mills a Owner: Ackley Date of Inspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b low grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene other(explain) Dimension Capacity: gallons Design flow gallons/day Alarm prese t Alarm level: Alarm in working order: Yes_ No_ Date of prev ous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBU ION BOX:z (locate o site plan) Depth f liquid level above outlet invert: Comment Inote if le el and distribution is equal. evidence of solids carryovgr, evidence of leakage into or out of box, etc.) DC PUMP C AMBER:_ (locate o site plan) Pumps working order: (Yes or No) Alarm in working order (Yes or No) Com ents: (not condition of pump chamber, condition of pumps and appurtenances, etc.) rev 1SeC 9 2 /98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corttinuid) 'ropo"Address: 183. Old. Mill Rd.. , Marstons Mills Owner: Ackley Date of Inspection: 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: l . leaching pits, number:� '7 12. leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condilion cf soil, signs of hydbau failure, level of po�ding, mp soil, condition g�vegetation,,�etc.) / �C y� CES OOLS: (locate n site plan) Number nd configuration: Depth-to of liquid to inlet invert: Depth of olids layer: )epth of cum layer: Dimension of cesspool Materials f construction: Indication f groundwater: i f ow (:esspool must be pumped as part of inspections Commen (note co dition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.) PRI _ (loca a on site plan) Mate als of construction: Dept of solids: Dimensions: Com ents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PAR(9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Nop"Address: 183 Old, Mill. Rd.. , Mars—tons Mills 1iMf1 : Ackley Date of Inspection: 771i—c� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) pG ti �r s 6° 1/ '_"ev:.serd G 2�9E. PaRt.10ofII . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION Icon*%Jedl ropertyAddress: 183 Old. Mill Rd- , Marstons Mills owner: Ackley Date of inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited O'nservation Wells checked Moderate Deep Groundwater depth: Shallow SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater rgFeet 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.) D termined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers JUsed USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revises 9/2/95 Page 11of11 TOWN OF B STABLE LOCATION SEWAGE # ®03 23 VILLAGE !2lls�`SI'e425 M-,Mr ASSESSOR'S MAP & LOT G-5 ^Z4 INSTALLER'S NAME&PHONE NO. SW Y20•-97 SEPTIC TANK CAPACITY f O LEACHING FACILITY: (type) 5',Sa0 �o�l��u CUe=ll (size) NO.OF BEDROOMS BUILDER OR OWNER' PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac 'n faci ' ) Feet Furnished by 5 !. "9 .' `l9 i . z0' 3 s' N.�,�,� �� v 0 ADDRESS : 014NERS NA.HE : SEWAGE PERMIT NO. : � NEW: REPAIR: 71*e-cc 6 0-lj DATE -I-S� I e r L4 i5L DATE 'INSTALLED: i INSTALLATION OF: ((Y4j�j�,T-rQ WATER TABLE : t 50 FINAL. INSPECTION BY: DRAWING OF INSTALLATION ON REVERSE SIDE : O R � z A� �� bra a' Az- A3-Sy 3 �-sD S No. aql ; ^ � e Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Miopaa.r 6petem Congtruction Permit Application for a Permit to Construct( . )Repair( k,,6pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.1Z3 0/ /W/ Owner's Name,Address and Tel.No. rhgrsrvhs rh%//s f h�/gyp Kirby Assessor's Map/Parcel 6 -20 a lei,%/ �Jav roris' Yf1,I�s Installer's Name,Address,and Tel.No. 'a8-�/2O' q73$J Designer's Name,Add s and Tel No. 5^b�39-/—�7�3 c9as�pti 1�� [3Arros q �� G�h�.rFr��� Type of Building: Dwelling No.of Bedrooms 5' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when a licable) fA 5,rr/J Yf l_,0O �� , Li=,0Gh 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 Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. igne Date Application Approve Date vr" �±E 3 Application Disapproved for the following*reaso Permit No. Date Issued ` �3 - - -------------------------------- ---- No. Oa�n, j—1 , OFee �© THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION,`'tOWN OF BARNSTABLE., MASSACHUSETTS r Application for construction Permit '• Application for a Permit to Construct( )Repair('j�Kp grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./$3 O/ /,V/// Owner's Name,Address and Tel.No. h•,grsrvhs �///s ph,%,p K%rby Assessor's Map/Parcel /�`20 g U M�// (, /C!�/ �ts,v-S rates° YJ1,!•/s ,��� = v SG�39y-2723 ,,. Installer's Name,Address,and Tel.No.S O$'�f� y73g Designer's Name,Addr s d Tel No., t)we k 1)-& l3,gePvs q .S�%r✓�G/ .� M, M,//s 1 /S" uH Sr7`" Drl vi_ 119r�lo vTl Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building' No/..of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title /, + Size of Septic Tank, -� Type of S.A.S. e Description of Soil ` y� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure theconstruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued_by this Board of Health. rgne a�iLll?i Date��` Application Approve Date 1 3 Application Disapproved for the following reasons 3 �✓' Date Issued Permit No. � 35193110 � .. a -THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ' (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (G�Upgraded( ) Abandoned( )by Jttl 4 a�e_ 12. reeo at 8 3 Old i I 12W 6A�,-STv45 Wl/S `r has been constructed in accordance with the provisions of Title 5and the for Disposal System Construction Permit No. �� dated Installer !/elj "0 19-e, 84i ,r ,3 Designer 15/5Y!//G/_=„S The issuance o this ermi shall not be construed as a guarantee that the sy`stem w unc ' gs desig Date S 2 d ��3 Inspector J a --ram —,,-- --- ---------------- ----- No. dam`' 77 —a3 1� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS &5po5a[ *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( pgr de( )Apandon( ) System lccated at /g3 0/ !'del, 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:Cons ion ustt be completed within three years of the date f this � it Date:_ �/4 3 �/ Approved by + f Helene Delaney : i183 Old Mill Rd ` .A a� Marstons Mills,MA 02648 O AIW 19V /y `tea Entoaed Q: Parch .e'VL - ' �e f e C4 ;�y .� C"ap M OP f °° 80 cis Not �i�m � Deck y" Bally ry v►a P a pQ� J 1� � a��' , a.l.Iln s bob Bath d Living Room DWng Roam C 46 Bedroom Den u i.. . SBAY u NE Bedroom N Parch f c °c Z@.Q' 2R.tff Fbst Flout Second FIW IW Drawn to Sods ------------------- ---------- 4 'ON 'Q'TAATDARD ]VOTES GROUND SURFACE O.P GROUND SU"ACL TlffS PLAN IS FOR THE LVSTALLATION OF A SEPNC SYSTEM. AEN -ir AWWRO"ENTAL CODE, OUYL& PIF� LEVEL 2) ALL INSTALLAY70N PROCEDURES AArD AIAT HAt"CONFORM TO 310 CMR 15.000, 71 Y 57, e- ,ngLff S vi D Pmgz, Tim PEE7 Nr REQ um TOP EL 5, AND THE TOWN OF ---- SUBSURFACE DISPOSAL REGULATIOAT. 4 T )PER INFORMATION UTH RECORDED mQ um i.r W.I MIN 2 LAYER DO BLC WASPED 3) NO DETERADNA 7YON HAS,BEEN MADE AS TO COMPLIANC,-OF A!7A��ALLF PR TY, Foci 0);4A 5t, --A 277s_)-�.t $Err 1AS O-BOX OR ZONING,REG VLA TIL 10" J :*I TER SERk7CAS THIS PROPERTY. INVERT EL 4) TOWN �WA 'T RE ARE NO "OWN PRIVATE YELLS ON THIS PROPERTY OR WDRIN 100' OF TtfE PROPOSED SOIL ABSORPTION SYSTEM SIDE rA L 1 5) HE GAS BAFYZE AT 0 U71ET INVERT EL 6 S7�f BAS' ALL COVETS ,OF SYSTEM COMPONENTS SHALL BE BROUGHT TO KTHIN INISHED GR_4DE, KTH,ONE- COVER OF THE VVVERT EL: _12"� OF F Ir b4 1 ,1/2' DOUBLE. SEPTIC T"K.BRO[1CHT #7TWN 6 OF CRADE MVERT E r4l,�, - I - I , I P L . I ccxl 5-ft .0 - Box 3/4' V�SHED STQNE � 7) L& SYSTEM COPONENTS ,SHALL REMAIN ACCESSIBLE fiUR. ,WSPECTION. I NO STRUCTURES,SHALL BE LOCAT5D D)RECTLY 4 Irg-k BvrWRT EL (Typical) ra IArWRT RE -COPONENT ACCESS LOCATIOS, WHICH WO ULD INTERFER E, 6" STONE BASE UPON OR ABOVE THE E 07TH 'TH PERfilORAlANCE, ACCESS, INSPECY70 it Ir TTOM EL 00 a 6 G, I Septic Tank PbWPING OR RE PAIR. Y BE LOCA TED ABO VE A SOIL ABSORPTION (Typical) _4-7 8) , NO DRIVENA , PARU) G OR,TURNING AREA, OR OrHER IMPERVIOUS AREA A41,L i5 r/Ai EL—, BO Jf 'OF TEST HOW :' SYSTEX 'EXCEPT WHEN FENTING HAS BEEN PRO P7DD. 9) _SEPTIC T"KS. -GREASE TWS, DOSIVG CHAMBERS AND DISTRIBUNON B017S SHLL BE PLACED ON A 6" SYtNE B E AS ?4 TO ENSURE,STABILITY AND PREVENT.SETN"C. LE TH 0) OUTLET DJSTWBU7I9N LINES SHALL REMAIN. LEVEL MR AUN11MUN OF PHE FIRST T#70 FEET OF NC AD UN PHEY ARE tINDER OR WITH .11) ALL SYSTEM COMPONENTS SHALL BE CAPABLE OF #7TNST4NDIWG H-10 LO ING LESS IN 10' &lr OF DRIVEXA IS OR PARIaNG OR,TURWING AREAS IN #MCH CASE H_10 COMPONENTS SHALL, BE USED 12) % ALL BUILDINC SEWER LflVES SHALL HA VE AN LVNER DIAMETER iOF 4 AND SHALL BE CAST-IRON OR SCHEDULE 40 Pvc BEEN PRO 13) , THE DEPTH 'OF, rHE TOP OF ALL SYSTEM COMPONENTS SHALL VOT EXCEED 36 UNLESS. VENYYNC HAS WDED. 14) N WE AREAS OF EXCA VA TION, EMSTING GRADES SHALL BE REESTABLISHED ONLESS NOTED AS PROPOSED ,CONTOURS 77ON OF 7HE SOIL ABSORPTION SY57EX, THAT DIFFER NOTABLY FROM '50 15) IF SOILS ARE ENCOUNTERED DURING THE EXCA VA 42'42'15 THE DEEP OBSERVATION HOLE LOG, CONTACT THE ENGINEER BEFORE PROCEEDING. � s 16 CONT(M CTOR TO, VERIFY LO CATION OF ALL UNDERGRO UND UTHXTIES. Exist DIW DESIGN DATA 7, DEEP OBSERVATION Number of Bedrooms: HOLE LOG , 'Garbage Grinder: Hole #1 NU Test (EL soil f Design Flo q 0 Horizon TIrtl. N� (110 Gal/B�/Day x Number of BR) (USDA) (Munselo /0013 6 - Septic, Tank: mum Desig A ovo n F1 07.) (Mint r7l Leaching Arew , 5A A/0 A I - t Sidewall: Deep 0 Date: X soil'Eval eo Pero Ratw. X + H61e (,Z Sidewa (ZEndwaHs x �—MYt q Soil S n: CARVEA urvey Devorlotio Bottoiriv terial: bUrYASH Geologic MR -2 Depth to Standing Waten, YA —L—yt Depth to Weeping Water-. NA X I L 0 Dep Long Term' Acceptance a e NA R t - (L th to Mottling(Color). NA (t�D ' / - , i. . 1 11, 1 � : . - f .. I ,, I'' TAk): 0. 714 tin Well:- A t=S Obverva Leadhin a nt� Date of lAst Menstu mt NA Are Design apaci y. , Comments: -0 Sidewall Area + Bottom Area) X LTAR /0 ING (ry D LEACH A 14C 4 C: PROPOSE ACILITY' .." � Fb ' B :'6 24 , dee Ur rG '000 Gal Conc t mbe P P 'wi s one on , S_ Tonk t -- sides, - r6 wl ­34 _X ib D 'Edx .(T tal , NSLOW t ........... Pump and K11 Ez&ting Pit .. .... (�s equired) r......... :r0p Test Pit, P 41 Location 'WA, '-. 590,6 PROJECT L 0 CA TION LOT ASSESSORS MAP T. PPUCAN . Aj leg 41 e� t�Y'�.Ti( _LAV pREpA 0 RED BY�.! A M land Set4PJceS 7 j/ r 15 Sunset Dii ve S u o' th Yarmouth, MA 02664 (508) 194 23 4� SCALE!. DA TE.-7- RE K LOCUS, MAP D WG. NO, SHEET 0,P , 0 17 L LAY '00