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HomeMy WebLinkAbout1455 OLD POST ROAD (CT & MM) - Health r `1455 Old Post Road Mdrstons Mills - - A = 057 - 067 i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every page. CitylTown State Zip Code Date of Inspection inspection results must be submitted on this form. InsPection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out mput on the computer, use only the tab 1• Inspector: key to move your cursor-do not David J. Burnie use the return Name of Inspector key. NEIGHBORHOOD WASTE WATER SERVICES Company Name 350 MAIN STREET Company Address W.YARMOUTH MA 02673 City/Town State. Zip Code 508-775-2820 S1386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addresis and thane information reported below is true, accurate and complete as of the time of the inspuec#ion The insp�tion was performed based on my training and,experience in the proper function and,inailnte- . ` `of on."s e system inspector pttrsuan#to Section 1 sewage disposal systems. I am a DEP approved3�1 Title 5(310 CHAR 15.000).The system: ❑ Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-12-14 Ins Asignatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within`30 days of completing this.inspection. If the system is a.shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner sha11 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 r do at the�e of in;s and.under the cones Of Use at that time.This inspectim does not address howthe system. kk to ft*JM,UWI.e the same or different condWons of'Erse. f � Title 5 Official Form:S�n'face Sewage D• System'Page 1 of 17 {$ins-3/13 �y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marston Mills MA 02648 5-12-14 required for every State Zip Code Date of Inspedion page Cityrrow n 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 rem, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, NO)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 exliltration or tank failure.is imminent: System,w l: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 A 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 ❑ NO(Explain below): Title 5 Official tnspedon form:S�surface Sewage Disposal System•Page 2 of 17 t5ins-3113 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every Cityrrown State Zip Code Date of Inspection page. B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired.. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of 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 e by the the env of ro Health e in order to determine if the system is falling to protect public 1. System will pass unless Board of Health.determines in accordance with 310 CNIR 15.303(1 Hb)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 Tdle 5 omcjW trispectim Forth.Subsurface sewage Disposal System-Page 3 of 17 t5ins-3/1 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every State Zip Code Date of Inspection page cityrrown 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due town 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 in or available volume is less than .day flow Tdie.5 Ofridel hrpection Fam:Subsurface Sewage Disposal System Page 4 of 17 t5ins•3/13 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information its Marstons Mills MA 02648 5-12-14 required for every City/Town State Zip Code Date of Inspection page. B. Certification (cost.) 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(allure-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: ® a 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.faciNty with a design flow of 10,000 gpid 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 4Q0 feet:.of.a surface drinking water supply ❑ ❑ the. ystem is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is locafed 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. TNe 5 offidal Inspection Form:subs zlem sewage owposat System-Page 5 of 17 t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form 's Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every City/Town State Zip Code Date of Inspection page. 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 NIA) ® ❑ 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. El ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: . 3 3 Number of bedrooms(design): - Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for r xample: 110 gpd x#of bedrooms): 330 gpd Title 5 O fiael In,pedion Form:SubS+uface Sewage Disposal system•Page of 17 t5ins-W 3 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments wM 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every CitylTown State Zip Code Date of Inspection page. D. System Information Description: The system consists of a 1500 gallon septic tank, d-box and one 6x6 pit with 2'of stone. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No ❑ Yes ® No Seasonal use? 12-134.2 gpd Water meter readings, if available(last 2 years usage(gpd)): 13-93.2 gpd Detail:. Sump pump? ❑ Yes ® No Current Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gaiions per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged.to the Title 5 system? El Yes ❑ No Water meter readings, if available: Title 5 Offidel motion Fond:subsurface sewage Disposal Systern'Page 7 of 17 t5ins•3113 > l Commonwealth of Ma' ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills — MA 02648 5-12-14 required for every Cityfrown State Zip Code Date of Inspection page. D. System Information (cont.) Last date of occupancy/use: Date other(describe below): . General Information Pumping Records: Serviced in 2006 per WPCF 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/Alter native 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): Title 5 Official hupection Form:Subsurface Sewage Disposal SYstem'Page 8 of 17 t5ins•3113 I Commonwealth of Massachusetts. Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments ' 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 34 years old per prior report done in 2006. _ Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 21" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments(on condition of joints, venting, evidence of leakage, etc.): The sewer line was in proper working condition and showed no signs of leaking or structural problems. Septic Tank(locate on site plan): 11" Depth below grade: 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 1500 Gallon Dimensions: 51' Sludge depth: Tdle 5 official lnspection Forth:Subsurface Sewage Disposal system-Page 9 of 17 t5ins-3113 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is MA 02648 5-12-14 required for every MarStOnS Mills State Zip Code Date of Inspection page City(Town D. System Information (cont.) Septic Tank(cont.) 36" Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" _Tape measure How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was in proper workingcondition and showed no signs of leak in or being overfull. 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. scum to bottom of outlet tee or baffle Date of last pumping: Date Tide 5 Official tmpec tw Form:Subsurface Same Disposal system'Page 10 of 17 t5ins-3113 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is MA 02648 5-12-14 MarStons Mills page. Clty required for every /Town State Zip Code Date of Inspection , D. System Information (cont.) . Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 t5ins•3/13 Commonwealth of Massachusetts Title -5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every 6k Town State Zip Code Date of Inspection page. D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): 011 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.): The distribution box is in proper working condition and showed no signs of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ .No* ❑ Yes ❑ No* Alarms in working order: Comments(note condition of pump chamber, condition of pumps and appurtenances,.etc.): *if pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: The SAS consists of one 6x6'pit with 2'of stone. Title 5 Official inspection Form:Subsurface severe Disposal System•Pap 12 of 17 t5ins•3112 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments „ �'" 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (coot.) Type: number: 1-6x6 pit with 2' ® leaching pits of stone. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.):: .: The liquid level in the leach pit was within 4"of the invert of the inlet line. The system is in a state of failure and needs to be upgraded. _ 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 cessp 1 Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every state Zip Code Date of Inspection page- Cityrrown 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.): Tine 5 Ofridal k*pedion Form:Sufuurtaw sewage Disposal System•paw 14 of 17 t5ins•3/13 f C Commonwealth of Massachusetts. Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Y 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every State Zip Code Date of Inspection pace. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately Title 5 Offiaal Inspection Form:Surface Sewage Disposal System•Page 15 of.17 t5ins•3/13 ksBuilt Page 1 of 1 TOWN QF BARN STAB LEE ySS Q_sT R LOCATION SEWAGE fi VILLAGE. C OR+ - ASSESSOR'S MAP&LOT M? INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 1,r00 LEACHING FACILITY: (type) A-r . . (size) NO.OF BEDROOMS 3 BUILDER OR OWNER 9A S PERMI'TDATE: 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) Fit Furnished by '1_ IZ2 alOn J .• . A/G. Z004z 3 8 C a9 10 y 3 �Y l8 3� 3� _ Y . I ittp:Hissgl2/intranet/prop4ta/prebuilt.aspx?mappar=057067&seq=1 5/12/2014 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills _ MA 02648 5-12-14 required for every -- State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Site Exam:- ® Check.Slope ® Surface water ® Check cellar ® Shallow wells 30'+-per prior report done on 6-12-2006 Estimated depth to high ground water: 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: SDW 253 ZONE C 34 LEVEL-48.57 ADJUSTMENT=3.7' You must describe how you established the high ground water elevation: The elevation on Old Post Road is 35 and Eagle Pond is at Elevation 18 which is a 17'seperation. The leach pit is 9'deep with and adjustment of 3.7'for a total depth of 127,This puts the leaching out of known groundwater. Before filing this Inspection Report,please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t5ins•3113' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Road Property Address Charlotte Roberts-Messner Owner Owner's Name information is Marstons Mills MA 02648 5-12-14 required for every CityRown State Zip Code Date of Inspection page. 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 Title 5 Offiaai hspedion Farm:Subsurface Sewage Disposal System•Page 17 of 17 t5ins•3/13 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1455 Old Post Road �Q Marston Mills. MA 02648 Owner's Name: Betty Paska Owner's Address: 3�id Date of Inspection: July 12, 2006 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT €= r�+ 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 basedon my':: training and experience in the proper function and maintenance of on site sewage disposal systems. I am aa.DEP', approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ' C=1 t ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Alority � - Fails Inspector's Signature: Date: Ju ly 12 2006 The system inspector shall sub ' 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 1.0,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection 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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1455 Old Post Road Marstons Mills MA Owner: _Betty Paska Date of Inspection: July 12. 2006 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 detennined(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 cbstructed 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: 1455 Old Post Road Marston Mills. MA Owner: Betty Paska Date of Inspection: July 12, 2006 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 forn. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SEWAGE DISPOSAL SUBSURFACE G SPOS L SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1455 Old Post Road Marston Mills, MA Owner: Betty Paska Date of Inspection: July 12, 2006 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 detennined 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: 1455 Old Post Road Marstons Mills. MA Owner: Betty Paska Date of Inspection: July 12, 2006 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. ✓ _ Detennined 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 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addres s: 1455 Old Post Road P Y Marston Mills. MA Owner: Betty Paska Date of Inspection: July 12, 2006 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: I Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [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: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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 infonnation: The tank was pumped after the inspection for maintenance 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: I 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: Installed on 11124180-per as built card 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: 1455 Old Post Road Marston Mills MA Owner: _Betty Paska Date of Inspection: July 12, 2006 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: 12" 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): zertificate) (attach a copy of Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" 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: 101, How were dimensions determined: MeasurinQstick 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 were nresent. The Quid level was even with the outlet invert. There did not apyear to be any si ns of leakage. The tank .vas bumped after the inspection for maintenance 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: Continents(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: 1455 Old Post Road Marston Mills MA Owner: _ Betty Paska Date of Inspection: July 12, 2006 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: gallons 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: / (if present must be opened) 1 p )locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was level and clean. No solids were Present. PUMP CHAMBER: A'one (locate on site plan) Pumps in working order(yes or no): Alanns in working order(yes or no) Coirunents (note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 w ► Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1455 Old Post Road Marstons Mills, MA Owner: Betty Paska Date of Inspection: July 12, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 Qal.)w/2'stone-per design plans leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): There did not appear to be any signs offailure. A video camera was used for the inspection 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): Cormnents (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 i ti Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1455 Old Post Road Marstons Mills. MA Owner: Betty Paska Date of Inspection: July 12, 2006 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. A �rvnT � C a- � Q C 3 aq io 3 y y 36 3� 10 !f ' !I Y Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1455 Old Post Road Marstons Mills, MA Owner: Betty Paska Date of Inspection: July 12 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- 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 Barnstable topographic and water contours maps the maps were showing approximately 30'+1-to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been 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 septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 TOWN OF BARNSTABLE LOCATION 11/5$ pL D 9oS 1 RcL SEWAGE# 201 y- ZyS VILLAGE M_ in; ASSESSOR'S MAP&PARCEL .S'I - L`l INSTALLER'S NAME&PHONE NO. B i' (3 CXQO V,.A;OJT N'1 -OGS3 SEPTIC TANK CAPACITY ASS00 9a LEACHING FACILITY: (type)' Soo od ckarA.5 p (size) 13 x ZS x 7- NO. OF BEDROOMS 3 OWNER (�c PERMIT DATE: 7- 2 T- 1 y COMPLIANCE DATE: 7/30 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 AV, �9 ' . 8V /o A3" Gy,6 B3- yG' A g Ay G7 'G' t� 3 4 No. i/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4pliLatlon for ]Disposal 6pstrm Const union Permit Application for a Permit to Construct( ) Repair t Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address o ot oA6�0f,p,,,� Owner's Name,Add ,and Tel.No ?9- Assessor's Map//Par/cel Installer's Name,�ess, d Tel.No. Designer's Name,Address,and Tel.No. 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(min.required) gpd Design flow provided gpd 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 applicable) �� i'° J lo Date last inspected —IZ— Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions 4Bo ' ronmental Code and not to place the system in operation until a Certificate of Compliance has been issued by �Si �.G�!J�i Date � - I Z Application Approved by Date / Application Disapproved by Date for the following reasons IPermit No. C1>__ Z3 1�0- Date Issued No.r4"'/cq— `� �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC'HEALTH DIVISION - TOWN O �BARNSTABLE, MASSACHUSETTS 2pplication for VsposaY pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade' y Abandon( ) ❑Complete System ❑Individual Components Location Addre s, oylLot o j��QJ /�Ja Owner's Name Add3eesp,,and Tel.No. 0P11 Assessor's Map/Parcel /� /�^ 5`7 4A MI IWloXG Installer's Name,Address',,911d Tel.No. Designer's Name,Address,and Tel.No. Type of Building: . Dwelling No.of Bedrooms Lot Size sq.8. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil t Nature of Repairs or Alterations(Answer when applicable) yy/�l/1/ ✓��'S yfl 6 /J Date last inspected —/Z— 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 o e Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo c)/o eal Signe / ---GPI G Date S-A/7— Application Approved by �.__ Date _ / Application Disapproved by Date . for the following reasons i 4 Permit No. r �` Date Issued 7 A a THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at )q.5 Al t `has been constructed in accordance 1 with the provisions of Title 5 and the for Disposal System Construction Permit xo.�Yd `— I.3 Ddated Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall,not be construed as a guarantee that the system will'functiomas esi dgned. Date / / r" Inspector - -------------------------------------------------------------------------------------------� ------- No. Q 0 3 G Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposar 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade ) Abandon( ) System located at 7 ,455 GXC.� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. �� Provided:Construction must be com leted ithin three ears of the date of this a irin t. P Y P Date / ��. Approved by� No. U Fee Id U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pprication for Misposal *pstrm Construction J)rrmit Application for a Permit to Construct( ) Repair()Q Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No.1455 Q, DS 1 I Owner's Name,Address,and Tel.No. 5D8-90 Assessor's Map/Parcel 57 � jb1 t Me S'j(y In((sst�taller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. o.J3 � �1CC• �S ��� �7� 'O(oS3 �Wh 1, 1.31 '��C��I Type of Building: Dwelling No.of Bedrooms 3 Lot Size l!' 1�- sq.ft. Garbage Grinder(�) Other Type of Building (,� a No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 3�-1 gpd Plan Date 1TI�y Number of sheets I Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �"b bA AV)a a- 500 Chain � Date last inspected: 3 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accoreance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Comp_iance has been issued by this Boar ealth. Signe Date IN Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ILI, 6 Date Issued r' No. U y ( _ Fee /U V computer: THE COMMONWEALTH OF MASSACHUSETTS Entered in p uter: ; PUBLIC HEALTH DIVISION `- TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpIicatiou for Disposal 6pstern Construction Permit Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No: qi ') ()14 i Owner's Name,Address,and Tel.No. '�Gb Li)U Assessor's Map/Parcel 5� �p t Flay l b I�1° }��(� )i� , ����� V61 ( 02�� Installer's Name,Address,and Tel.No. Designer's Name,_Address,and Tel.No. bib tiAc . Type of Building: i f ^� l t ; r YY II Dwelling No.of Bedrooms 3 Lot•Size"— sq.ft. Garbage Grinder( N) Other Type of Building rF�1 !11 ((;+' No.of Persons Showers( ) Cafeteria ) Other Fixtures Design Flow(min.required) 33o gpd Design flow provided J 9C► gpd Plan Date 1 I�ILI Number of sheets Revision Date Title Size of Septic Tank V)UU� Type of S.A.S. t)�UGGI� ��1u �h(rj Descriptiod of Soil Nature of Repairs or Alterations(Answer when applicable) bX �V)A a boo c r I o yy)�(. 1 Date last inspected: T 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 Certificate of Compliance has been issued by this Boar ea!- " . 11- - r> rt( Signed c Date Application Approved by /X`` k7( Date c Application Disapproved by Date for the following reasons � / \ it Permit No. 7 u E'y , .Z }! Date Issued ----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at �� V� 0 a�� .,, /� �� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dW- ted 2-O •Installer `� �J �X( GNU( lUn •Designer NwYl �(l O� �Y�11(1 P�1�1 1 1�( #bedrooms Approved design fllo and The issuance of this permit s 1 t be cos e as a guarantee that the system will ffinction as de ig,e Date Inspector F — - - - No. _o Fee AV THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS -isposal 6pstem Construction Permit Permission is hereby granted to Construct(C ) (Repair( ) Upgrade( ) Abandon( ) System located at ")� V�(� i u J' �t�1 i �` �� `�� {`�11� I� �y�p UZ(p�i S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provid.,d:Const9ction mint be completed within three years of the date of this permit. Date Approved by '\ J VA• IJi OF L'L2 ? hole e5 fie: TIRO las F. Geffer, Director r ti4PJJSTas2�)'•ems. Tablic Health D1-val s on ... .. f Terms McKvzn, Director IGo Main Street,JHyam",T U 02601 Office: 508-862-4644 Fax: 508-790-6304 !T'nstaH,_gy &Designer Certni'fncation Foam. Date: �' Sewage 1�err,�nn>t �i0t T Assessor's l �iplJParcel�(� Des>i�Tiere J CAle Address- "f 7 Gl L C-A Address: C2� on 1 3 14 was issued a permit to install a date) —V (installer) septic system at based on a design drawn by (address) .1LfcL- Pcc /it dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. r I certify iihat the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. plan revision or Certified as-built by designer to follow. �Aa *soh OF 4df,4 DANIELA. yes (Installers Signature) 01 !A CIVIL C No•4Q602 . � � 7 111 y ��'�S o s T (Designer'sS igrtail]Ie) (Affix Desig�e-'Sal]lI7 ere) pLIEAs-E FIST JE I TOBARNS1ABLE FURLIC HEALTH DIVISION. %EvTiMCAT—E OF C011U.�aE de� =4 � H in z 655ei a��d'��L �Abu � S +� 1�� r.S-BUILT BARD AIRE R E CIEMD BY TBE BA iSTAB LE RIMLIC BEAL b H DIVISION. TRA241K YOU 0:Hearth/septic/Designer Certification Fo-im 3-26-04.doc Town of Barnstable P# y' Departinent of Regulatory Services Public Health Division Date 6 �7 ae79 200 Main street, yanais MA 02601 Date Scheduled ,Il Time 7/ ,, � Fee Pd. ►oil Su , "bilio .Assessment,fir Sew - e ,� r `� Performed�By: �a h r ,0( 6cn S;a I u e- Witnessed By: LOCATION& GENE AL INFORMATION Location Address /�1�T a /4 Pv r�- D-Q D Owner's Name M Lp / Address Assessor's Map/Parcel: S—�7 (O 7 Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use: La utj Slo es % P ( ) V surface Stones lC1e C•.-, Distances from: Open' Water Body r�C >fG[7 Y /^' R Possible Wet Area ft Drinking Water Well t'Q ft Dramag9 Way (w ft Property P nY Une 3 0 ft Other ft SIM'TCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands•In proximity to holes) - u C • s9 Tr♦Z N t,3 :`b �p Parent material(geologic) (0 >�� Depth t9 13edrgck Depth to Groundwater. Standing Water in ,Hole: IV14 Weeping from Plt Fnae / Estimated Seasonal High Groundwater �lh DETERA/RNATZON FOR SEASONAL HIGH WATER TABLE Method Used: 416 WE Depth Observed standingm obs.hole: - ` la. Deptt to soil mottles: ln, Depth to weeping from side of obs,hole: In. Groundwater Adjustment Index Well# Rcadiag Date: Index Well level Adj,Actor,,,,,.,..,,_,,,--.Adj.Groundwater Leval— ,,.__,,,._, Observation PERCOLATION TEST Date Thus /1/ " t Hole# l/I Time at 9" ,._,,,.,•'____, _ LQ � Depth of Pere Time at G" :start Pre-soak ll'lmc @ �J "`� �� -- Time(V-0) .End Prc-soak Rate Min./lach 'Site Suitability Assessment: Site Passed t Sitq Fallcd: Additional Testing Needed(YIN) ;Original: Public Health Division Observation Hole Data To Be Completed on Back------- ***If percolation,test its to be conducted within 100' of wetland,you must first notify the.. Barnstable Conwvation Division at least one(I) week prior to begiltlWng. Q.-\S EPTICIPERCPORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture .Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, o i ten,y�96'tiravel) 3q:-3y 3y- o L 4a-1 z� C2'Sy �l0' DEEP OBSERVATION HOLE LOG Hole# Z Depth from Solt Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. -Consistency.9a O ve 3o-3 3 y-yo � • � S �0 YR y�� ](SEEP OBSERVATION HOLE LOG Hole�. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulders. -- - coll5i5tgnry, Gmycll ]DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil 661or Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Cositn y Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No `!" Yes Within 100 year flood boundary No. Yts Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas obstrved thrpughout the area proposed for the soil absorption system? y-e S If not,what is the depth of naturally occurring pervious matariall Certification I certify that on S�// �— (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the requited/training,expertise and experience described in�10 CMR 15.0177/. Signature /� � Datb 7/l Q:\5.E11r1aPERCP0RM.D0C �. �. ° Pj nj a .. E L c0 Postage $ f1J Certified Fee ReturnReceipt Fee ,Q Postmaitc O � (Endorsement Required) Here a 0 C` Restricted Delivery Fee ] O C3 (Endorsement Required) J ' � / I O Total Postage&Fees CO Charlotte Roberts Messner TR r % CRM Nominee Trust 1455 Old Post Road Marstons Mills MA 02648 Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. , IMPORTANT-Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SEN'D'ER:�60IPLETE THIS SECTION . . ON DELIVERY ■ Complete items 1,.2,and 3.Also complete ;L:: =X S' at e item 4 if Restricted.Deliveryis.desired. ;ter/ ❑Agent 0 Print your name and addres on the reverse X(` 2`U/ Addressee SO that We Can return the Card t0 you. B. Received by(Printed Name) 0. Date of Deli:ery ® Attach this card to the back of the mailpiece, ` 6j!) or on the front if space permits. If D.is delivery address different from item t? 1 Yes 1, Article Addressed to: If YES,enter delivery address below: O No Charldtte Roberts Messner TR I % CRM Nominee Trust E 11455 Old Post'Road 3. ServicelYp e Marstons Mills, MA 02648 ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise. 0 Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 77 2. Article Number t I (transfer from service label 7 0'12 =1`010110 0 0.0 = 2 8 51" 3 6 7 2 Ps Form 3811_February 200d Domestic Return Receipt 102595-02-M-1�— UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS i Permit No.G-10 • Sender: Please print our name, address, and ZIP+4 in this box • I P . Y I I I I _ � Town of Barnstable i Public Health Division k 200 Main Street ' Hyannis, MA 02601 I t J I I p DIME Town of Barnstable Barnstable ` Regulatory Services Department AMMWWBCN MAW "M Public Health Division DtA 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #'7012 1010 0000 2851 3672 June-2 0, 2014 Charlotte Roberts Messner TR % CRM Nominee Trust 1455 Old Post Road Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located at 1455 Old Post Road, Marstons Mills,MA, was last inspected on 5/12/2014, by David J. Burnie, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system" Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Liquid level in the leach pit was within 4" of the invert of the inlet line. The system is in a state of failure and needs to be upgraded. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. R OF THE BOARD OF HEALTH omas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\14555 Old Post Road MM Jun 2014 doc.doc r SHE Town of Barnstable Barnstable T�ti P °* Regulatory Services Department e"aC f 9 BA, MASS.LE,� public Health Division MASS. �A i63q. �m I fD MAC a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A. McKean,CHO CERTIFIED MAIL # 7011 0470 0001 4525 7260 June 25„ 2012 Ms. Charlotte Roberts Messner 1455 Old Post Road Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at, 1455 Old Post Road, Marstons Mills, MA, was last inspected on 5/4/2012 by David J. Burnie, a certified septic inspector for the State of Massachusetts. Since the necessary repairs were done, there is no further action required, However, it is recommended that the tank should be serviced every 2 years. It is also recommended, that a filter be installed on the outlet of the septic tank.. PER THE BOARD OF H�FALTH DsJMcKea�nR. �CH Agent of the Board of Health G Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\1455 Old Post rd.,M M.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your [% V cursor-do not David J Burnie use the return key. Name of Inspector David J Burnie Mgmt, Inc ICI Company Name 307 A Commerce Park North Company Address r S Chatham Ma. 02659 City/Town State Zip Code 1-866-980-1440 SI 386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: a ❑ Passes ® Conditionally Passes ❑ Fads, - ❑ Needs Further Evaluation by the Local Approving Authority w Q Inspector s Signatur Date s The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. vv Wiormrface 5 I1t5ins•11/10 Title 5 Official InsSewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) t 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: System is a 1500 gallon septic tank, distribution box and 1 6x6 leaching pit 2/3 full 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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): distribution box is rotted and needs to be replaced. K-e- �4 a C. e d ❑ 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•11110 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 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. CitylTown 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 asurface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 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 9 P Y rY M 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 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 ❑ 0 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ` ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): permit 495 gpd t5ins•11/10 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 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 gallon septic tank, distribution box and leaching per permit dated 8-19-80. System per permit included use of a garbage disposal. Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): yes Detail: 2011 81.000 gallons= 222gpd........2010 51.000gaallons= 140 gpd. 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11110 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 , 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Pumped at time of inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? Truck site glass Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool. ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑, Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: permit dated 8-19-80 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 27"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): ' Distance from private water supply well or suction line 10+: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Ok as to what we can see. Septic Tank(locate on site plan): Depth below grade: 15"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) Concrete tank some decay. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2-4" Distance from top of scum to top of outlet tee or baffle 22" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be serviced every 2 years.We recommend a filter be installed on outlet of septic tank. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 54-12 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•11/10 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 M , 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 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 Normal 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.): New distribution box installed by permit on 5-9-12 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: Located and viewed using a sewer camera. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 w Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit was 2,/3 full 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-11/10 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 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 " page. CityrFown 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.): leaching pit was 2/3 full 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-4-12 page. City/Town 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 thins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner owners Name information is required for every 2 page. Cityrrown State Zip Code IYA4 of Inspoction D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building.Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately /CSC = r3 p ROOT _ i I 4 t5hp•11n0 ride 5 OMW Dion Form 80wfm Searapa 04coel System•Pam 18 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for every Marstons Mills Ma. 02648 54-12 page. C:itylrown 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: 30'+/- 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 - I ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: prior report. dated 7-12-06. Water maps Barnstable estimate water at 30' below grade. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Prior report dated 7-12-06. Water maps Barnstable estimate water at 30' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1455 Old Post Rd. Property Address Charlotte Roberts Messner Owner Owner's Name information is required for everyMarstons Mills Ma. 02648 54-12 page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L __ LO ,CATION6a SEWAGE PETIT NO- ," ' — VILLAGE INSTALLER'S NAME & ADDRESS 1 ® U I L D E R OR OWNER D,e Paln 9 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Z41-7 �/�� I _ 1 5. i %� � Ro�T. 2�- y" N � � � � � � � � ..a. \ ,� '' � ��r�cc� f No((Y)d " Fps... .............. THE COMMONWEALTH OF MASSACHUSETTS I` BOAR® OF HEALTH 0(N.. Appliration for Disposal Vorks Tonstrnrtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 6)! d- r Vt d- • . 1,ta&4aH s N L Us - L v r s' 0-a T-u t t CLOSE— ................ -_.... ........................ -----------------------------------•-------------........------......_•-•--•................. Location-Address or Lot No. ......1.. a !, 'b e '[?a m �S 1 5 s 0 t c2 Pa s r • -.......---- --. .... ....................•.... Address W �� ✓. ..if Cw..6't V v �'" e wt.¢r, U t I/1 t 'W�a�4 6 a - ----------•••-• -•-•--•-•---••...............•••--.........._.....�Q.S. y-........-----•-••-••. Installer Address Type of Building 3 Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ✓� Other—Type of Building __._ ......_... No. of persons.........._—............ Showers ( ) — Cafeteria ( ) Otherfixtures ..---•-••--...--••••-------•-•••• • -----------•-•--•............ -•••••......------•-•••••••••.... W Design Flow...............JSf....................gallons per person per day. Total daily flow...........-R 5__._____.._._____._....gallons. WSeptic Tank—Liquid capacity...:s..Dgallons Length................ Width................ Diameter................ Depth................ Disposa l Trench—No.._._.._. ._._.. Width.................... Total Length.....................Total leaching area. ................... ft. x Seepage Pit No......k_____________• Diameter...:1.0............ Depth below inlet..... .._......... Total leaching area...266.......sq. ft. Z Other Distribution box ( vT Dosing tank ( ) Percolation Test Results Performed by-••••-•••-•......•---...----•---...---••--•--•---•••- ---------- Date........................................ W Test Pit No. 1....?-_.......minutes per inch Depth of Test Pit-__.L_ ........ Depth to ground water..____"--0'vL4-_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P' ....................----•-•• ............................ o Description of Soil---n..._.__Z1.. ...... a^^^- S`-s®t W x 1 _ 1 2.1..-.. V ••••-••--••••••-•••••-•-.....-•-•...........-••-----.-•-• •.....��....e!....`!......-3 --x.a2----------------------------------------------------•-----...------•--------•- W U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. --------------------•-------•-----...-----------........----------••--------....-----....----......-----.....---•-------------------------•-----•-------------•----•-------- •--•••-•---•----------••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I' 5 of the State Sanitary Code—The undersigned further agrees not to place-the system in operation until a Certificate of Compliance has been issued by the board of health. Si ned �J '� D d4 -------------------------------------------- :-------- -----5--- --------------•---------•------- Date,- Application Approved By..... 1M .01�.� = � Date Application Disapproved for the following reasons:--•••-• •---•1_._.- - ---•---•----------••-------•-----------•-------•-----------•a••.............. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OFMASSACHUSETTS BOARD OF HEALTH .............-To rny':............OF........!,a't!k`?t c ................................................ ApplirFa#ion for Disposal Works Tunstrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ; ...... ..... ....._..............o-! ----'4 .. -- .. o. s_.1M.ii1........------L°-r-- =-........... . . g. . ...-------------- Location Address or Lot No. ......01.9... ..r ....;D 1 n. .��.t �.S........................ ....�.4! ...Q 1�.YP.�r.....A.a.... i an Own r Address ....._. ... .. 1+ C van.�t°_l�. .� .!. !- �_ wfi ..V.►iA..<...'4!>u A.4._. Installer Address O 'I T_ Type of Building 3 Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder (wr Other—T e of Building No. of ersons_.........-=............ Showers — Cafeteria G-I Other fixtures ................•--------------•......-----••----- W Design Flow................4F!....................gallons per person per day. Total daily flow.......... .�.'....._.._.........._.....gallons. WSeptic Tank—Liquid capacity.•..... gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No................... Diameter..'M.......... Depth below inlet................. Total leaching area...21A......sq. ft. Z Other Distribution box ( VT Dosing tank ( ) •-' Percolation Test Results Performed bY........................................... ............................ Date........................................ ,aa Test Pit No. 1....Z........minutes per inch Depth of Test Pit.....(.1......... Depth to ground water.... AA.-_ (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 � i....................................................................................... ...................... O Description of Soil... ' ........... ? se q r I z� 1M t 2 t'a'►tit S a V.�. U .--•----•----------- ------------•- --------------- •------------------------------------- -------------- •..-----------•--- W UNature of Repairs or Alterations—Answer when applicable................................................................................................ •, -----•--••-•------------------------------------•-•----------------------------------••--•---------------•-----------------------------------------------------------------•-••-••-----..._----.....---- Agreement: The undersigned agrees .to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT:1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ........ Date Application Approved By........ ... --. 4444. .....................•-•----• � "��-. .�...... Date Application Disapproved for the following reasons:................. ............. -------•--...-----...-•----....----•----------------•-------...........------....--•-----•-•-•----•-•------•---•------•--•----•-•----•---•.- " Date PermitNo......................................................... Issued......................................................... Date ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ .......OF............ ... ,! 1................................................. CIn#ifirate of ToutpliFanre THC-5,4S TO yCERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by (�. - .................... .. .. ..... .. ... at U Ins Ilex has been installed in accordance with the provisions of TPT-IRj of The State Sanitary Code as described in the application for Disposal Works Construction Permit No -_- WI.............. dated.r----162_'-_I1"..F4d.-----_-.- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARtNTEE THAT THE SYSTEM WILL FUN TION SATISFACTORY. DATE................ Lf 90.................................. Inspe'ctoL�__._.�=./-'---�-• - ---------------._--------••-_ THE COMMONWEALTH MASSACHUSETTS BOARD CF' HEALTH / ............OF.......y . . .a4k. ...`............................................ Nog...y��.... FEE...�Id---........ io1 , �rsontrionernti# Permission 's reby granted........ ...................••----•----•---- -------•--••----•---•----•-••- to.Constru ( /for;RWi, ( )pan Indtivi 41 Sewage i osal Systj at No..'- ---- t f��r.�1_ -... p = t •..... =/.-f:. • Street as shown on the application for Disposal Works Construction o.:P it N ../.`_..... �jDated".. �. .:.. ��...... /0_ G_ / Board of Health DATE............ / -•-------•-----------------------------------------•--•-------- i' FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ~ V C--S t .;.t.i tlln'IrA 7 O�tt��{ �t.pew,/ a Il0 •t � +��O/o'd'g5�ir.P.R �.___--� SE.PR G T A�.►k • 33o X 200 %= Cpt.+O�� � � '. � u;E L�oO Go•A�- 7�ao '%>15PoSAL PIT ygE laa� Grtcl2'SToL , BCOTTOAA a TOTA,` TaF�►6h1• i —"�'.. j f =►�?r C1 ; r71 ! t t ' PE¢�c�L�•T to�..i Q6.TL- t i W Z mw o2 L rut +T/4 �j- `..�Tr At. .-�41 A y IYAL �� 1 © 91Er0 �O • F /-�G ° 99 TOP F&JD loo' riot-Ez �L- 9'7 -�c `t ELF 97 MW LoARI 4'D.rE 1 Zvi ,f• �9G SJF35otc. �'Pvc DKT tt 4dC.. , 9s•G Zone aw 2 i►iv. t TA U tL ; 6PAL. 9S Lr�caa 9s�T.. v Pt T ti SAW> wasui� ccaa w 6 �� 89 CEQ T t Ft ED Pt.o-r PL-A N Pll¢o P,t 1. A.T-IOW ,(�AtLSTptJS Lt,5 EL-9S I Z No Scwt,.r. 5C,&Lr= (I� : Lv© U AT c-- 15/14 t cccTtFY r"AT T'"Sm ��U LLt IJEo 51,•to�u►.� "av-e.o1.a1 WtTN T"a. LOT s At.JD 'Sk`C'8ACK %ZF4oier--MML4T; OF 'Z"1.1E /'_ T TbwtJ OF Q �J'rt (�f� p�TEs. S d�ao `p L • >4 �2$ 21s�t S•i"6. ZZt� L At.1 D �Q�IE`(r7e� TWA; PLAW 1i, WOT $A5ED OW AU II.KT&)INEj►lT OSTEaRVtt_t_c. MAye�, 5vevMr 4 TkArm OPPMT; -5"OUlb 140T $E I�SeA To DETatZMtUE %.c? LtuE�. APPL%C.A.wT QIu�A�r, �i, AtM tJ�t.•IS TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: 1455 Old Post Road, Marstons Mills 02648 MAP NO. PARCEL NO. OWNER NAME: Richard L. De Pamphi l is VILLAGE: Marstons Mi I Is INSTALLATION DATE: none BY: No underground tanks ave been instal led at this location ADDRESS: CERT. -NO. TANK INFORMATION LOCATION OF TANK: CAPACITY TYPE AGE FUEL/CHEMICAL TESTING CERTIFICATION E I PASS E ] FAIL DATE LEAK DETECTION E I CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION E I YES E ] NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED E I YES E I NO DATE CONSERVATION E ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ ]E ]E ]E ]E 7 DATE PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION 1 �r OWNER AND INSTALLER INFORMATION / . 1 ADDRESS: 1455 Old Post Road, Marstons MI 1 Is 02648 MAP NO. PARCEL NO. OWNER NAME: Richard L. De Pamph i l l s VILLAGE: Marstow Mi l Is INSTALLATION DATE: none BY: No underground tanks bw been Installed at this location ADDRESS:. - ., ------ CERT. _NO.. . . TANK INFORMATION LOCATION"OF TANK: CAPACITY TYPE AGE FUEL/CHEMICAL TESTING CERTIFICATION C ] PASS C ] FAIL DATE LEAK DETECTION, C ] CHECK- .IF N/A TYPE/BRAND , - ZONE OF .CONTRIBUTION - C ] YES . C . ] NO DATE TO .BE REMOVED FIRE DEPT PERMIT ISSUED C ] YES C ] NO DATE CONSERVATION E ] :CHECK IF.; N/A DATE BOARD OF HEALTH TAG NO. E ].0 ]C ]C ]C ] DATE . PLEASE PROVIDE A SKETCH SHOWING THE TANK LO.CATION.. ON THE BACK OF THIS CARD TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION ~m OWNER AND INSTALLER INFORMATION ADDRESS• 1455 Old post Road, Marstons Ml i Is 02648 MAP NO. PARCEL NO. OWNER NAME: Richard L. De Pamphi i is VILLAGE: Marstosm Mi i is INSTALLATION DATE: nOge BY: No under ground tanks Eta, been installed at this 1 ocat i on -..ADDRESS=::..: - -- - - - - - -- -- TANK INFORMATION LOCATION OF TANK: CAPACITY TYPE AGE FUEL/CHEMICAL TESTING CERTIFICATION E ] PASS E ] FAIL DATE i LEAK DETECTION E ] CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION E I YES E ] NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED E ] YES E ] NO DATE CONSERVATION E 7 CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ 7E ]E 7E JE ] DATE PLEASE PROVIDE A,SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD NOTES ALL SYSEMSYSTEM PROFILE RKEDTNTHCMAGNETICTTAPE OR BE 1. DATUM IS APPROX. NGVDF PROVIDE MIN. 20" WATERTIGHT ACCESS (NOT TO SCALE) COMPARABLE MEANS FOR FUTIJRE LOCATION. 2. MUNICIPAL WATER IS EXISTING COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CAST IRON WATERTIGHT COVER TO GRADE TOP FOUND. EL. 56.5' FILTER FABRIC OVER STONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. Route 28 d \ MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEA' S0.0 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS TO BE AASHO H-2Q I�d�stt R Locus PRECAST H-10 WATERTEHT D'BOX FOR LEVELNESS BLOCKS OR / PRECAST RISERS 5. PIPE JOINTS TO BE MADE WATERTIGHT. PoSERS (iYP.) 2'0 J4"OSCH4-0 PVC MORTAR ALL54.0INVER'i IN 46.5' IPES LEVEL 1ST 2' [� COMPONENTS ENDS (n'P') s1oEs 47.5' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCEWITH 310 CMR 15.000 (TITLE 5.)TEE TEE ®® �'EXISTING 1500 GAL. 52.6 * o t6IN SUMP ° ®®®®®®®®®®® ®®®®®®�'L�®®� ° ° °` 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND -+o00000 O o o c o O O 00 0 0 ° °oGSEPTIC TANK•* �ogo� N. INT. DIM. N ° ° ®®®®®®®®�®® ®�®®�®L�10�0� ° NOT TO BE USED FOR LOT LINE STAKING OR ANY o y GAS BAFFLE':. 46.77' 6' ° ° ®�®�®®®�®®® ®®®®�®�I���� ° J OTHER PURPOSE. a v� .Cv ° ° 44.5 } 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ° ° `H-20 500 GAL. LEACHING CHAMBERS BY ACME PRECAST OR EQUAL e Rd �y 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR o Boxter N ALL AROUND PRECAST STRUCTURES CONCEALED WITHOUT INSPECTION BY BOARD OF d �° 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00 X 12.83' COMPACTION. (15.221 [2]) -to OF AND PERMISSION OBTAINED FROM BOARD *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL OF HEALTH. UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS (18.8 % SLOPE) ( 1 9: ' PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM - SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP H-20 LEACHING CALLING DIGSAFE (1-888-344-7233) AND FOUNDATION- EXISTING SEPTIC TANK 31' D' BOX 12' FACILITY 3s.5' IorroM TH-1 VERIFYING THE LOCATION OF ALL UNDERGROUND & NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT WORK. 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE ASSESSORS MAP 57 PARCEL 67 WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE (OR H-20 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SEPTIC TANK IF IT WILL BE SUBJECT TO VEHICLE LOADING). SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND SAND. 99- EXISTING CONTOUR X 99.1 EXIST. SPOT ELEV. 99 PROPOSED CONTOUR QD 198.41 PROPOSED SPOT EL. O (0 I TH1 21319 SYSTEM DESIGN: ITEST HOLE I I Y FENCE GARBAGE DISPOSER IS NOT ALLOWED 2% SLOPE OF GROUND ST�CKADE POST&RAIL FENCE . � EXISTING 3 BEDROOM DWELLING UTILITY POLE O 1 j o DESIGN FLOW: 3 BEDROOMS © 110 GPD = 330 GPD FIRE HYDRANT / USE A 330 GPD DESIGN FLOW NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING � MAP 57 SEPTIC TANK: 330 GPD (2) = 660 j EXIST. PARCEL 67 TEST HOLE LOGS GRAVEL �� USE EXISTING 1500 GAL. SEPTIC TANK X 0. 47 AC. + DRl VE LEACHING: ENGINEER: DANIEL E. GONSALVES, SE #13587 I I �W o ow SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD W 237 GPD �� / . (.74) = WITNESS: DONNA MIORANDI, RS BOTTOM 25 x 12 � � DATE: 7/16/14 q BRICK I ��%� , z TOTAL: 472 S.F. 349 GPD 2 MIN INCH< v W � I � PERC. RATE _ / i�� � / USE (2) H-20 500 GAL. LEACHING CHAMBERS CLASS I SOILS P# 14424 \ (ACME OR EQUAL) WITH 4' STONE ALL AROUND 03 ELEV. ELEV. Z1 24.6 00p 4 50.0' 0„ 50.0' y - 00 2 ,gyp I o N � 3g.5, FILL FILL H1 1 S�OGKPD MA EE \ APPROVED DATE BOARD OF HEALTH 30" 30" J 'LINE TYP•) TITLE 5 SITE PLAN A A �cA / - �. S� OF LS LS gyp\ l 0" \ �0�' „ 10YR 3/1 10YR 3/1 ° - 34 47.2 34 47.2 s 1455 OLD POST ROAD � MILLS MA B B � � � � PROP. VENT WITH CHARCOAL FILTER M A R S T O N S , Q AND BUGSCREEN (FINAL PLACEMENT BY LS LS / \ N CONTRACTOR WITH HOMEOWNER PREPARED FOR BENCHMARK.• REAR FLANGE CONSULTATION) 40" 10YR 4/6 46 7, 40„ 10YR 4/6 46.7' O BOLT OF HYDRANT B&B EXCAVATION/MESSNER ELEV.=48.74 (NGVD) MAP 57 C C PARCEL 68 DATE: JULY 16, 2014 PERC 117441 �w,aA. , t c 'f "� off 508-362-4541 M/CS M/CS % OF/ sc$� , �� ` �\T� fax 508-362-9880 O GAtJiELA s "'° Gt ;;rl a downcope.com 2.5Y 6/6 2.5Y 6/6 o 03 0J :_A �^s A.Oj AU down cape engineering, inc. oNo.4E": 126" 39.5' 120" 40.0' _4- o ���� �r.. ci vi/ engineers s=��, �n land surveyors NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 /��/�� or qi s �" � 939 Main Street ( Rte 6A) 0 0 20 3o qo 5o FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 DCE # 14- 153