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HomeMy WebLinkAbout1525 OLD POST ROAD (CT & MM) - Health [525 Old Post Road Marstons Mills A = 058 — 035 I OC A.MhN. .S S. lG OS SEYJAGE L . VTT:I ADE / v ci �� 11S ( ASSESSOR '� INSTAt.LE 'S PIAi i'HtJI N SEPVC TAN.k A�dit �QZS� LFACFIIPiG�FACI�'i°I tt ) � (size) 'OPBEDR: MS bUI 15ER OR OWn ER AERMFFDA'I'E. t)IV#�'T��cN�DA. Feet Separation Distance Betweci the Maxintutn Adjusted�sroundwaterT61e to che;Botto .....f Leaehtng Faci ty ' -Private Water-Supply Well and Leaching Fa lls exist on sita:or within 266 fit=' let-ng kw- Feet Edge of Wetland and-Leactung}"�aq't ty(If any wetlands exist within 300 feet d eactung facirlty) eet Furnished b `'' {�t°c. D'FEE r 1 Lr n� t 13 •-c- A _�..as� �. a ,D - 36 ., f Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1525 Old Post rd Property Address David Ballerini Owner Owner's Name / information is required for every Marstons Mills V Ma. 02648 6-29-20 — 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 A. Inspector Information 5� �lt(Pa•(p filling out forms on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites path Company Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes ��` •. � MICHAEL %N 3. ❑ Needs Further Evaluation by the Local Approving Authority To. SEARS No.SI14430 0) 4. ❑ Fails *: �F �° 'o� 20 iNSp��A��``` 6-29-20 Inspector's S' ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 5, 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1525 Old Post rd Property Address David Ballerini Ownfoner Owner's Name requir required is Marstons Mills Ma. 02648 6-29-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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): t5snsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c � Commonwealth of Massachusetts Iti Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1525 Old Post rd u Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cost.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): D box walls are gone needs to be replaced ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5 nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f c � Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 1525 Old Post rd Property Address David Ballerini Owner Owner's Name in.ormation is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form N& i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 1525 Old Post rd V� Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary. (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 i cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1525 Old-Post rd V Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form + IIb Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1525 Old Post rd Property Address David Ballerini Owner Owner's Name nformation is -equired for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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): 330 Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1525 Old Post rd V� Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203):. Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 12-31-18 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form h I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 1525 Old Post rd Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 26" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 1525 Old Post rd V Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 16" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? sludge Budge, 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.): 1500 gal tank withinlet cover at 7" and outlet cover at 16" below grade inlet and outlet tees t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts A Title 5 Official Inspection Form _ 11; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Bch / 1525 Old Post rd V Property Address David Ballerini Owner Owner's Name information is Marstons Mills Ma. 02648 6-29-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, ligWd levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 1525 Old Post rd Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection l D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is at 20" below grade 16x21 with 1 outlet pipe. Box is no good needs to be replaced t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form v I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 1525 Old Post rd u Property Address David Ballerini Cwner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): �h * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1- 1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: tainsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... !% 1525 Old Post rd u Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 1000 gal pit clean and dry no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts r,j Title 5 Official Inspection Form _ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1525 Old Post rd v— Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 1525 Old Post rd u Property Address David Ballerini Owner Owner's Name information is required for every Marstons Mills Ma. 02648 6-29-20 — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately O O J I 3 ' �s . so N t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �- Title 5 Official Inspection Form IIIiI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1525 Old Post rd Property Address David Ballerini Owner Owner's Name information is equired for every Marstons Mills Ma. 02648 6-29-20 gage. City(rown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show ground water 20'+ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I r I i y � c Commonwealth of Massachusetts v Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 1525 Old Post rd Property Address David Ballerini _ Owner Owner's Name i.1formation is Marstons Mills Ma. 02648 6-29-20 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 9' m A .SAS 4 Jq Al o g: A wo+pf- t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts f dJ�_�J W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 C' /Town State Zip Code Date of Inspection page. �y P P Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information IMM 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev ation by the Local Approving Authority 8-7-15 4wreec,tor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. LOW 4S t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.. M 1525 Old Post Rd Property Address Mike Didenzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ' ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 ears old is available. P 9 Y ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. Cityrrown State Zip Code Date of Inspection 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 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: El Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I`_ N Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: I I I I I_ ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface 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: r i D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the.distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than Y2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection-form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ' ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El El Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments M 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is Marstons Mills MA 02648 8-7-15 required for every _ page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ' ® ❑. Pumping information was provided by the owner, occupant, or Board of Health ' ❑ ® Were any of the system components pumped out in the previous two weeks? El ® Has the system received normal flows in the previous two week period? El ® 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 + t been determined based on: ® ❑ Existing information. For`example, a plan at the Board of Health. ®• ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 7• r i i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�' 1525 Old Post Rd Property Address - Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. Cityrrown . State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 7-2015 Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day Y(9Pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r , 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner—pumped 10 yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool T ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 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: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet 4 Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 1211 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) f: Septic Tank(cont.) ' Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness � 11 ' . ' 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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-3113 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 s ' 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments M 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. Cityrrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No*. Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1525 Old Post Rd Property Address Mike Didenzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. , ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and holding 12" of water with stain line at 16" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 IL Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments 1525 Old Post Rd Property Address Mike Dirienzo Owner Owner's Name information is , required for every Marstons Mills MA 02648 8-7=15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1525 Old Post Rd Property,Address Mike Dirienzo Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 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 r f D k r - P-7 I,f f 5, -- c r .4 4/91 t5ire•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, M , 1525 Old Post Rd Property Address Mike Dirienzo - Owner Owner's Name information is required for every Marstons Mills MA 02648 8-7-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: .. ❑ Check Slope ❑ Surface water 4 ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed- Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database.- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 " Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1525 Old Post Rd Property Address Mike Didenzo Owner Owner's Name information is required for every Marsto.ns Mills MA 02648 8-7-15 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 t5irs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 N � � Fee 7si®') THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for Nspo8Af 6pBtrm ConstCULtion j3Prmit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System trffidividual Components Location Address or Lot No.15 d Owner' �=an Assessor's Map/Parcel Vut 5 � 4 Installer's Name Address,and Tel.No. �D Designer's Nam AddAss and A.No. Type of Building: Dwelling No.of Bedrooms 1,3 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 M�� Nature of Repairs or Alterations(Answer w en applicable) C 't Date last inspected: +: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the EnvironmentA Code alld not to place t e ystem in operation until a Cert'ficate of Compliance has been issued by thisFardofh. & . 6, Signe Date .Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued 4 r No._q)d —.Jo) Fee St" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye— PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Zisposal *pstrm Const action Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) [:]Complete System ndividual Components Location Address or Lot No.16Z5 0 Owner's Name Address,andTel.No Assessor's Map/Parcel V 11� 5) Installer's Name,Address,and Tel.No. Designer's Nam Add ss,and T No .. 17 Type of Building: Dwelling No.of Bedrooms S, F2 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 t Size of Septic Tank Type of S.A.S. Description of Soil ��-✓C7� /4PP A_ L Nature of Repairs or Alterations(Answer when applicable) �..�.. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment Code and not to place the system in operation until a Certificate of Compliance has been issued by this of�th. Signed Date 6 Joam Application Approved by Date Application Disapproved by Date { for the following reasons Permit No.. Date IssuedJ` --------------------------------------------------------------------------------------------------------------------------------------- ` THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) epaired(Upgraded( ) Abandoned( )by at r has been constructed in accordance ,p ` with the provisions of Title 5AA and the for Disposal System Construction Permit 14Q �o'kC I dated -2 Installer tV't Designer #bedrooms Approved design flow -- and The issuance of this permit s all not b construed as a guarantee that the syste� will func ' esi ed. Date �,����� Inspector l - -- - - - ---No. -------- ------- - --- Fee -�_ __= -- _. - �j / r THE COMMONWEALTH OF MASSACHUSETTS �1 PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pst(�Prl .eonstrUction Permit Permission is hereby granted to Construct( ) Repair , Upgrade( ) Abandon( ) t . Fyn located at and as described in the above Application for Disposal System Construction tprmit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction st be/completed within three years of the date of this pe it. Date Approved by No. ...: b.. 4 Fims... _............... ,.- THE COMMONWEALTH OF MASSACHUSETTS� a BOAR® OF HEALTH Town Barnstable -•----- - .........................OF.............................. ..... ApplirFatiun for Uispuual Works Tunutrnrtiun unit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: Lot 1 ................-----............................................................................ ----.....••••-•-----............--••-•....-•-•--....------•----------------------......_.......... Location-Address or Lot No. Route 28 _ _ ----.....-•--•-......_ _.... .. ...... ..........--............................................................................ ... ow r Falmouth Roa dareotuit -� Installer Address U Type of Building Size Lot....3 6_,7 5 8------- Sq. feet �-, Dwelling—No. of Bedrooms.................3---... --. --..-----_.Expansion Attic ( ) Garbage Grinder (X) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ---------------- W Design Flow.................5 5..........._._._....-_gallons per person.per day. Total dail flow.................3 3 0 _ zallons. 11 WSeptic Tank—Liquid capacity...1.5 0_(�allons Length.l 0'-6.". Width..5.�. ��_.. Diameter...:............ Depth. 4. x Disposal Trench—No..................... Width:---................ Total Length.................... Total leaching area........._..........sq. ft. Seepage Pit No...__.--.1.-.-...-.. Diameter.....14- ....... Depth below inlet 6 -.... Total leaching area....4.0.3......sq. ft. Z Other Distribution box ( X) Dosing tank ( ) '-' Percolation Test Results Performed by.-_Cape Cod Survey Consultant�te 23 March 19$4 -- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_. r3 Test Pit No. 2........2.....minutes per inch Depth of Test Pit 12.._..... Depth to ground wate ��OF_ a 9 O Description of Soil.......TP#l; 0-42" topsoil & subsoil; 42-72" med. v,-------------------------•----------------...••-•----••-••-•......-- U ��na W� bbl S 72-96 sandy ill 96.:..._162 W •• •••--•-•-•---------------- --------med- sand--w�L?ebble s. TP#Z---Q--3 6" topsoil & sub .302 x ls� V Nature of Repairs or Alterations—Answer when applicable so i 1 I_ 3 6-14 4" med.. sand ► lSxQ . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a cordance with S�3 the provisions of i,L , -; 5 of the State Sanitary Code— he undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' th o of health. •. --...... --...--•-----------•-••-•-•-•----••••--• ` ApplicationAppro B • • . . -••------••-•--•---••-••-•--•-•-•--••-•--•--•-................................... -_ ate Application Disapproved or a following reasons:----•------------•-----------------------------------........................................................ ...--•-•--••-•--••-•-----•-------•--•••--------------------------------------------------- ------ -------•--•-•--- Date PermitNo......................................................... - Issued....................................................... Date r i L 0 CATION SEWAGE PERMIT NO. VILLAGE a)9oe-S7V,l-S INSTALLER'S NAME i ADDRESS /ZM 6 D,5rvc-Z0ff"Cnrr Carl P - - ,97FiC--ie 96i /r1A,.v OsrnryiecO ® U I L D E R OR MN[ DATE PERMIT ISSUED DATE COMPLIANCE ISSUED /0ZZ���y ���� �� ,� �� r i ��9 �� � �. �.o .L. I �,`f ww r o _ N1 ....o...... FEs........................._... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTI-1 . ....--_...Town.............................OF..............Barnstable -- --................................... Appliration for Uiipniial Work.6 Tomitrnrtion anti# Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage. Disposal System at: Lot ••-•--------------••-•-•---•-- 1 Location-Address Route 2� or Lot No. •--•-- .......................................•---•----•----...---........-•---•- -- Owner a Falmouth RoaCZ ddretotult Instal er Address d Type of Building Size Lot....3.f>..01$.......Sq. feet U __..Ex Expansion Attic �., Dwelling—No. of Bedrooms..................3_.._.u.._.___._____ p ( ) Garbage Grinder (X_.l Other—Type of Building No. of persons............................ Showers a yP g ---------------------------- P ( ) — Cafeteria ( ) AOther fixtures ••-•--•---•-------•----•--•---•-••----•----••--•----------•-------------------------•--...---•--------------•-----......------.......----..._..---••- 330 W Design Flow................. 5.....................gallons per person per day... Total daily flow............._..._..__..__......_._.___.._._�lons. WSeptic Tank—Liquid capacity.._1 Q�allons Length__!-Q�6" Width.-5_�_8��,.. Diameter._.......____,.Depth_.5"4_11._. x Disposal Trench—No..................... Width-................... Total Length................. Total leaching area....................sq. ft. - Seepage Pit No.......... Diameter.....14?_'_...... Depth below inlet___-5.t67'- Total leaching area..... ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by...Cape-.COd_SUrV2y CQnsultanMte 23 1Karc water __ OFF sq LL4 Test Pit No. 2.._.._...2.._..mi minutes per inch Depth of Test Pit , i2_�...... Depth to ground water---- _ � - -�`T�-PHEN yN ------•--•--•---------...............................•--------.....--------........--------••-••--•••-• .AL-LYN O Description ofSoii_....__TP I.• 0-i42-" topsoil.- & subeoil; 42-72" meci. � ------------------- U ---------•-----------•••-•--•----•---_..sand -W/Pebbles►---.2.2-.9!6." san-ey.tlll� 96 162 ,& 0No.30216� W ........................................med..--.sand..ta pebbl .,<--TP 2 0 36 topsoil sub- �� c'ST U Nature of Repairs or Alterations—Answer when applicable$gil.r_...36 _144" cited. sand ��S/p L�w� .................................. -- --------••-••-•---•••-------•-•-----•---•--•••--------------••-------••-•--••-•--------......----------•----•-------•-----w/pebbles.-------------------•---- Agreement: G���u -s.>tivinY The undersigned agrees to install the aforedescr�bed Individual Sewage Disposal System in accordance with the provisions of T TT 11: i of the State Sanitar ode— The undersigned further agrees not to place the system in operation until a Certificate of pima e ha een issued by the board of health. r �• ate Application APPr e Date Application Disapp vlJorfollowing reasons:------••-•-----•---------------------------------•------------------•------------------------------------....._ .. .-•--------•-•--•-•-----••--•••---------............................................................------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............I............................OF.............................................................................. Trrtifiratr of Tuntpliatta TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) byV.._�... --- -�'- . ...._ ---- ------------------------------------------------------------------------------------------------ /(,� � �./�, � Installer at................................................................................................. � ( •. ....................... has been installed in accordance with the provisions o TL 5 of The State Sa.ni o a described in the application for Disposal Works Construction Permit No......................................... d-ated___.._-__-.-_-.-_-___-..-_--..___----_-______--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. y� DATE...............................!1?_.'.�✓?"__ .................. Inspector..... =�-�----------------------------------•---•---••----..........-- THE COMMONWEA;L7;H OF MASSACHUSETTS BOARD OF HEALTH T 0.. ....................... FEE........................ �.t gY $ f ratit Permissipeis hereby grant '' to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo...................................................................................................... Stre �"'� as shown on the application for Disposal Works Construction Pei I ..................... Dated.......................................... ---------------------•--------.-------•---•-••---••--•-------•----•---------•- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS P 7 ► E a REVISIONS: DATE OF TEST/NG: E� MAsic PERC. TEST DATA : SEPTIC TANK DETAIL : sizE- ; -�� �,�; ,��, .� DIST BOX DETAIL : LEACHING FACILITY DETAIL 1 -F 9-04 A4w a",v,gad TEST PIT DA TA s TEST BY: DATE OF TESTING.- 9� TANK TU CONFORM TO TITLE 5 REOUIREMENTS. TO CONFORM TO TITLE 5 REOU/REMENTS: T. P. . , -4a WITNESSED BY: �' ,,tee i tr_. rEsr BY� r�,�..s.�/ _- NO OUTLETS � 1 F -- -- ---- - —-- WITNESSED BY: 9, a; Mom-©�� - _��' �,�� — _ ��j� � REMOVEA,BLE COVER �i/� �� i�-7i-a'�iA /�i.�iTd'%/�7�'!/ta��/�'/����1�j� �•=\��"i't\��'—\�j\�\3.�������� ^fir 12 MANHOLE BROUGHT TO FINISH GRADE. j 2,•fEASTO/IE - ��Lao!MBFXL /2~AWX. A. T` 3 CLEAR 3 CLEAR "T OUTLET PIPES �— - - DEPTH OF TEST •72 N 6"M/N_�- 2„MIN 6„MIN ' AS REQUIRED r j, I �- INLET DIST �r 7y, l RATE: <z __ /0"M/N — I t INLET TEE ourLEr TEE \ , ( ; ; �'r i ApERs 5T INLET AND OUTLET 4 0 MINIMUM ; OUTLET TEE DEPTH '� C� /000- GAL. i • 4' L/QUIO DEPTH /4"'AT LIOUID DEPTH OF 4" 2 . " PTiiC A . �•. PRECAST OR BLOCK MM!' rEEs ro BE cAsr /g" 5 6„ SIE T hK 1 R Apf IRON, O BED. 40 I CONCRETE I, SEEPAGE PIT —-- DEPTH OF TEST: P VC. OR casT IN 24 j' J, ', v , o o. CONSTRUCT/ON 1 h I ° /0 t PLACE CONCRETE 29 ` , RATE: CONCRETE .. 34 " " " B� BOTTOM ON LEVEL STABLEBA.SE MIN �'�` i • .•t -- - CONSTRUCTION -_- - i (WATERTIGHT) ° /NL E T TEE PROVIDED WHERE SLOPE FOUNDATION - - - OF INLET PIPE EXCEEDS O.OB % OR -- T'` ' ' '- '° •- '" " ' TANK TO BEABLE TO W/rHSTANO / ,BOTTOM OF TANK ON LEVEL STABLE BASE y-/OLOAD/NG UNLESS UNDER /N A PUMPED SYSTEM. 20�Mm - I I - I/1� WASHED STONE t - - PAVEMENT OR/N DRIVE.H-20 i I L 0.4 D I NG UNDER PAVEMENT OR DRI VE. 141 - NO TES : INVERT EL E VA TONS: PLAN VIEW : I. THIS PLAN/S FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE DISPOSAL FACILITY ONLY. SCALE : / ZCa lNV. AT BUILDING ram• �'1CZ�� 2 AL L CONSTRUCT/ON METHODS AND MATERIALS SHALL CONFORM TO ©N� � � rsco�r �a�.?"`+3AGK. • ' ' /NV. AT SEPT/C TANK(/N) �?A s_-,r * MAS" D.E.O.E. TITLE 5 A ND THE - _ BOARD OF , , `1"►- _ INV. AT SEPT/C TANK(OUT) ,: I*'CAL TH REGULATIONS. 5 Z Fr q .j •!fj'W r. ✓tlA'(•�P� !�, RYA: ..f�f'i.-c'� '•d T.�I Q �_Ci'" ,,r.r::..._ � i�' INV. ArDIsT. Box(/N) a- .N � .,� INV. AT DIST. BOX(OYJT) AT LEACHING FACILITY: �� AT BOTTOM OFPIT. 7�.^ HALT AX, MASS. NORWELL, MASS. MASS. S� BEDFORD, MASS. LEXINGTON, MASS. HYANNIS, MASS. MANSFIELD, MASS. CRANSTON, R.I. DERRY, N.H. iC]5 �Er1G;� MARS Q/re� &-0 7- C,vcClJc.gri6,-V �v 4s5t1 MELD S vi DESIGN DA TA DESIGN FLOW: a REOU/RED SEPTIC TANK: _ �i' Jy o - _ GAL. T SEPTIC TANK PROV/DED = iSDGt- GAL. CAPE COD SURVEY REOU/RED SIZE LEACHING-FACILITY: CONSULTANTS --- - -- - PO. BOX 56 3.3 - -- -C� HYA(�tNIS, MASS. 02601 _� N - ------ - - --- -- 617 775 -7155 ,f ------ -- -- DIVISION OF BOSTON SURVEY CONSULTANTS INC. SIZE- OF LEACHING FACILITY PROVIDED: ENGINEERING • SURVEYING • PLANNING = TYPE OF SYSTEM: TITLE: q 90 — Y , . �" ;1�` '� tit 1 c:�r^ _ � ______- — �-���.�... ��9 �� x �: � •.� 6 z� �' - l L54 :.� x ; �-.-L�g _:r�- 4_- SEWAGE DISPOSAL SYSTEM 4 DESIGN �; D• 6csx i — 7- 4/1 P/T 4 iTDN� >° G `'�` -- ----- - ---- ;a 'rK,/•�S T iJ F TlLOCUS PLAN " T� -'� Mc,! 1 FOR 1 / i 1 n-' ' °+ r' SCALE: AS SHOWN METERS FEET 0 / J O� ' ° Q� ;' �' 1 a b �` � DATE: COMP./DESIGN: CHECK: R P M DATUMS DRAWN: v t3E N' C f1 FIELD: ^r! 7-o P C. $ . F'.•i t7. FILE NO: 46!5u#7 7 DWG. NO: t�✓c JOB NO: SHEET: I OF: I i _