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1575 OLD STAGE ROAD - Health
F11575 Old Stage Road 1,Iarstons Mills ` A= 151 — 008 - 001 II I �I No Fss.... ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ' CJW............OF... !WML�.................................... ApplirFation for 14spaii ai Works Tomitrnrttun ramit Application is hereby made for a Permit to Constr@t or Repair ( ) an Individual Sewage Disposal System (, ' �.a i 1 0� s'�'�c�,� A .....�-- - ............. . �� �----•- ------------....--------.•---------•------- ----'----g---Z..................... .Location-Address or•Lot No. U � � ...#4�►4 k�A---.aZV%A Z-k------------• ................... •--•-•-----------•--._...............----------..... Owner Address W Installer Address 3Z 1 Lv d Type of Building Size Lot_-_---•-1--_-_____________Sq. feet Dwelling—No. of Bedrooms_.._........ .....-5....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ----------_-_-----....................--- W Design Flow.....................�?5_____-___............gallons per person per day. Total d''aily flow.. ... �_Q..............gallon.s. WSeptic Tank—Liquid*capacity)�� q..gallons Length.. ."Q . Width_ . P.._ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length......7-...._�'_.. Total leaching area.�.SO........sq. ft. Seepage Pit No.........._f--------- Diameter....1.0......... Depth below inlet.�=�...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.TARXA.—X.....>V1t�V_S?_.f__ ......................... Test Pit No. 1____Z.___-_-minutes per inch Depth of Test Pit---------J.7...... Depth to ground water_.. Qlu_�_-:_. f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... P .....-'--•-------------------------------------------------'---......--------------------------.............................................................. O Description of Soil•--4� - _:.4� .gip AI.►SJ•_•_SVi3 �� Zt ltyljg D1.V.!A ....tA-)AJ W V ----------------------------------------------•------------------------------------.... ----------- W V 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 iITU 5 of the State Sanit e— The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has been is h b rd of alth. Sied.. ......... ----- ----- ----. .. ?. Application Approved By--' ' . . - ......-•-•-'--_...... .......•... `" " . " - -•---'---e----^--- --'- ....... - -- D ate Application Disapproved for a following reasons --q. -•-••-'-"'---------""•'--•-•-'-"'-------•'•-••--•--'--•'------'-"--•'-••-•--•......"-•-•-•-•-•••.--- f ------------------------------------------------------------- ----- -----------------'------------- ll Permit No...I / ..1.................... Issued._ � .Date Date .A. No.. .jam. Fmcl THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --.-----.--.OF....f?i.4 R S Appliration for Bispoaal Workg Toustrurtion rnmit Application is hereby made for a Permit to Constroa Or Repair an Individual Sewage Disposal System at: '�l Im I W< .. . ...... .. ..4 0,............ ............................ Location-Address" or Lot No. .....� _Ut"L .............. ................................................................................................. Owner Address .......... ......... ....... Installer Address 3a k-b 0-------Sq. feet Type of Building Size Lot-------)- --------- Dwelling—No. of Bedrooms........... A.............................Expansion Attic Garbage Grinder Cther—Type of Building ............................ No. of persons................._...._.__._ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow.....................5.5..............gallons per person per day. Total daily flow..4Y.C)-------*------------- .........gallons. - Septic Tank—Liquid capacit)IjP2��...gallons LengthA.1 --- Width;;?.....�.. Diameter................ Depth..._...._....__. Disposal Trench—No. .................... Width.._.._.............. Total Length......(...... I.... Total leaching areaZS.0.........sq. ft. Seepage Pit No----------I---------- Diameter...LD.......... Depth below inlet.S.-7:SQ........ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed byl"�Q__t.AtA..... --- --------- ........................... Date. 7:......1 1 ---Test Pit No. I----:;;;Tt ...minutes per inch Depth of Test Pit.........I*?....... Depth to ground water._N.Q_!!4._--------- 0z4 Test Pit No. 2................minutes per inch Depth of Test Pit___.............._.. Depth to ground water_.__._..._...._......_.. 9 .............................................................................................................................................. 0 Description of Soil....Q=... ....A"7�� S'i 5_> I'�• ...................... ........ ............... .............. U ........................................................................................................................................................................................................ ........................................................................................................................................................................................................ 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 TITLE 5 of the State Sanit -6,4e--The undersi ned further agrees not to place the system in t' operation until a Certificate of Compliance ha been is by h and o ealth. Sy'ipn-ed.......... .... .... .. .................... ......... ............ ....... a Application Approved By....... 115, 4 ............. ... ..... ate 7"--------C .. . ............ ...... . . . .. .. . . Application Disapproved for-`the following reasons .....................................................................................................- I� ............................................./....... ........................................................Z . . .... .................................. Dal Permit No.8--- Issue(L..L ............... Date THE COMMONWEALTH OF MASSACHUSETTS fBOARDAF. HEA H I-oo ............ ...... .......OF...... ......ke.....JE Trrftfirtttr of Toutplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by----------------------------------------------------------------------------------------------------- ............... -------------------*--------------------*--------------------- al at.... ....................................................... has been installed in accordance with the provisions of TI 5 of T e State Sanitary Cod s d I d in the application for Disposal Works Construction Permit No.-__-_- ....... dated I/KPIP1 V............ THE ISSUANCE OF THIS CERTIFICATE SHALL OT BE CQJ4ST S A GUARANTEE THAT THE SYSTEM WILL FUNCTIVONATI$*ACTORY. DATE................................. ................................ Inspector.. ........ .. ......... .................................................. THE COMMONWEALTH OF MASSACHUSETTS OARD OF 7....ALTH OF....... NO...... . ....... '" FEE.Jao. N ..... Disposal Works T-511notrudion "panfit I Pe-misslo"'s hereby granted......................................................................Z------------- ----------------*------ to Construct (V )fr Repair aa,,IidividualP. e Di al Sy t ........ .......... ----------- �7 Street a t' as shown on the application for Disposal Works Construction Permit No..1).....C Dated.._.-. 7 ............................................... DATE. .... ................. ------------------------- C�Moard of Health ........... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Commonwealth of Massachusetts Title 5 Official Inspection Form 0uuduridcc acwdyc vispVsdi Oysiem Bunn-ivCi i�i vCiuiliaiy haacaaf�}cilia 1575 OLD STAGE RD Property Address NAUGHTON Owner Owner's Name information is ::::::::--•":_- MARSTONS MILLS MA 02648 8/15/11 every page. City/rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. l"'ia`'rta"` 'Men filling out A. General Information forms on the computer,use 1. Inspector: only the tab key lll...YYY v to move your DOUGLAS A BROWN cursor-do not ,;se a e re_;m Name of Inspector key. DOUGLAS A BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVILLE MA 02632 Ieax City/Town State Zip Code 508-420-4534 JI429/ Telephone Number License Number B. Certification C� I WF illy dldi.I i1dVe pel SUf ldiiy If jtipUGIeU liW JCwctye UISFIUbdl Jy5ie111 dl LI 115 dUUle55 dflU lfldl LiIC -• infoFination reported below is true, accurate and complete as of the time of the inspection. The inspection was$erformed 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: r N Y n CConditionally Passes n F�ilc L',e— ; Needs Further Evaluation by the Local Approving Authority 1-4 C) i r ,�! _ 8/15/11 Inspector's gnature 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. ---"-I IIIJ I�i�,/VIL VIIIr YGJVIILIGJ VVIIYILIVIIJ qL LIIC LII II�i VI -- -- -• - -- --• - -' -- IIIJ'I�.VLIVII i.11Y YIIYGI LIIC VVIIYILI VIIJ VI YJG at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•,'09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 - . l \ ommonweahn of nnassacnuseuz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD !-'rnnFr�Ariri.tac NAUGHTON Owner Owner's Name information isrequ MARSTONS MILLS every paged for. MA 02648 8/15/11 evert page. CRy/Town State Zip Code Date of Inspection B. Certification (cont.) A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. v--iiiii--- ii.a. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be — -vaii—. i i is Sj%Sici i i, u'ia7i i a.vi7i�iiciiaii i Ji ii is i ci.iiai..ci i ici ii Ui i i;;Paii, cis 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 str cturallhj 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. F-1 V l=1 N rl Nn(Frinin helntv)- t5ins•09)08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I \ t.*ommonweahn of Massacnuseifs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD Pr-nFrnv Art'.. NAUGHTON Owner Owner's Name inormation is MARSTONS MILLS requiredfor MA 02648 8/15/11 every page. Cirylrown State Zip Code Date of Inspection B. Certification (Cont.) . v� vyaicTi vviwiaiviniiy i"aa�ca�i------ --- El 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): F— broken pipe(s)are replaced rl Y n N 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 cvafan?Ltirill nacc ir:cnonfinn if h rifh nnnrnyal of+ha F?nar:i of HP-al!h)- ❑ 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: L_I INIIUILIUlIS CXISI wllll,I IUI4UIIC IUIUICI CvdlUdLIUll Uy LIM DUdIU UI nUdlUl III UIUCI LU UCLCLIIIIIIC II 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 bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 \ Lommonvv hn of massaunuseub Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD NAUGHTON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 8/15/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ 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: P a6;a 6 ai ii is ricii iiviuci-ai iciiyoia, i.iciTvi i i icai at ci 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: v� vy:aicTi i aiiuo vi i�ci iw i�MYiiviauic av Piii v�ia'io�iw; You must indicate"Yes"or"No"to each of the following for all inspections: Yes No rl Backup of sewage into facility or system component due to overloaded or ❑ ® 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 Y day flow r \ wmmvnweakn vi Massaunuseiis Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 1575 OLD STAGE RD NAUGHTON Owner Owner's Name information is MARSTONS iMILLS required for MA 02648 8/15/11 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) IGJ IYV ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of:the SAS; cesspool or privy is-below high ground water elevation. n Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® 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 .,-...421-1..,.,..i. _ ..:1,.1, 7T6•:.. 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.] Thy system is a nessnonl s:?rvinn a facility Wth a.ctpsinn flaw of 900onrid- L_j 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. 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 Li Li iitc sysient is wiiitin WU MUL Ui a sutiaix utinKiny waiet 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 vn:i hne_a nnein•ararl'4ra_"f.n nnr n1 1n in Ser_finn F±hn cvcgcm ie rnneirla-a:+n cinn fr•ant•fhrPaf or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form auusuriacC Qewaue vispusui Oysienr rurnr-IVVI 1Ui vuiwiiaiy r�55e55tii@lii5 1575 OLD STAGE RD Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS MA 02648 8/15/11 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? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 1 IGVC la ga VVitJ111CJ Of WQICI NCCII 111\I UUU1,VU LV If 10 Jy DLGI II IV1,VI Illy VI GJ pCIIt VI 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? MM. 1-^ . ........ ...........:...:r_..:...: -o - _. _.__.. -__. ® ❑ 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. approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System information 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 t5ins-09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 0 %oommonweaiin of nnassacnuseifs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD prn�a-Iv arla.�� NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 8/15/11 every page. Cl rown State Zip Code Date of Inspection D. System Information ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND 2 500 GALLON CHAMBERS IN A 13X25X2 FT AREA Number of current residents: 2 Does residence have a garbage grinder? El Yes..[] No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No 1-dundry sysiwn inspeuied% j_j Yes Z42A ivo Seasonal use? ❑ Yes ® No Water meter'readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: P Date Commercial/Industrial Flow Conditions: Type of Establishment: --• r._.. L-__...- •n Aa- nnnx. wagons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease:trap present? ❑ Yes El No Industrial waste holding tank present? El Yes ❑ No IVVI I-sdl Ii Cdly WdbiC UIbU ldlyCu iV I[It: I It1C J SybtCl 11r. U YCJ Lj ivy Water meter readings, if available: t5ins-09M Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page-7 of 17 r \ %oommonweahn of massacnuseiis Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y 1575 OLD STAGE RD P:nr,=:�✓Arrlrrcc NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 8/15/11 every page. Crty/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: -- Date Other(describe below): General Information Pumping Records: r-r-a;i--t-: 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 Li oillyie ce5ziNUUi ❑ Overflow cesspool ❑ Privy ❑ Shared systern(yes or no)(if ves, attach previot;s inspection records, if anv) ❑ 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 pp of the DEP approval. t.__I VUICI �UC1l;IlUC). t5ins•09I08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 \ t#ommonweahn or Massacnuseuz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 8/15/11 every page. Cltyfrown State Zip Code Date of inspection D. System Information (cont.) ------ --- ----- --= ---= = .. /1t/rJIV41111QLG QI,G VI QII VVlllr./V116111J, VU—118-011GV�ii ni ii7Ylii i�di'U:wuiwc V1 ii 11W1 i P10-11. S.A.S INSTALLED IN SEPT OF2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet ' Material of construction: ❑cast iron ❑40 PVC ❑other(explain): ------:-------------:-------_--- ---- .... II VI11 h/l lvalc YY Qlril Q-FF y YYOII V1 JUVLiV I III IG: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 4+ feet Material of construction: Ipj UVIJUM e U nleidi j__j iiueryidsb LJ PUiyeiiryienc j_j uiiter kexNidinj - is iiicioi, ...•yyc: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: APPEARS TO BE 1000 GALLON Sludrle depth: t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f \ %oommonwealkh of 11a55acnu5e1M Title 5 Official Insp ection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't o 1575 OLD STAGE RD Pr-party Arlrlre-- NAUGHTON Owner Owner's Name information is regt.iredfor MARSTONS MILLS MA 02648 8/15/11 every page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) VC'J4IY Ig111- Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from ton Of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): 1 111Y1\IV Y[VI I L VLLI VV 1 11!\V 1\IVLI\V VLVVL. I V VI\lIVV Grease Trap(locate on site plan): vci+iii vcivrr yii;�c. feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): 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 viaic Gi IgJI iiuiiii.Jiiiy: Date t5ins•:09R18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 \ C*ommonweahn of nnassacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD Rrnrart+.•Arltiraa- NAUGHTON Owner Owner's Name informationerequired is MARSTONS MILLS re wired for MA 02648 8/15/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) VVIIIIIIVIIIJ�VII�/Mlllr./Illy IVWIIIIIIVIIV VIIVIIJ, II IIV YIIV VYIIV♦lVV VI V4111V VVIIVI\1V11, JlI4Vl VI VI II IIV yI 1lr, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YRS Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: IVIG\GIIOI VI WIIJl1YVlIVII. ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: si:ac-;y: 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 toommonweakh of Massaunuseus Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD r' np Hy adrlr� NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 8/15/11 every page. City mown State Zip Code Date of Inspection D. System Information (cont.) vaaa wuaw uvn�u ri cac is i iiioi iic GFici icu��iiit.idic Gi i oiic�.iioi i�: 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.): BOX LEVEL NO SIGNS OF LEAKAGE OR SOLID CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in wonting order: ❑ Yes ❑ No vvn nncnw�nvac wuw uvu ci runiN a.nanivci, i VI Full lv. di IV i;vvui ici iidi i—.s cii.... Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: DEPTH t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 f� Ys 8 12 of 17 �\ toommonweahn of massacnuseub Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD Prn-rrfy ArfrirRaa NAUGHTON Owner Owner's Name information is recuiredfor MARSTONS MILLS MA 02648 8/15/11 every page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) ❑ leaching pits number: ® leaching chambers number: 2 n leachinn galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: Li innuvatrveianuiriabve systern Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): vc.�arvvw�a.ca�rvvr r r woa vc r+ui r rNcu aao racer a vi n wrcwvi r� �rui:ia is vi i oii.c --'fai i'- Number and configuration Depth—top of liquid to inlet invert Depth of solids laver Depth of scum layer Dimensions of cesspool Materials of construction f inuludiiun ul yluunuwaier iniiuw j_j 'res Lj Nu t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 \ %oommonweahn of Ma55acnu5eu5 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD prnnpa Ar1:rfr=cc NAUGHTON Owner Owner's Name iequiredfo is MARSTONS MILLS required for MA 02648 8/15/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) VVIIIIIIVIIIJ`IIVIV WIIVIII VII ... - .-.•::. .•. . :...:..:... .:..:.: . ...........VI JVII,JIl,11J VI II�VIGVIIV IgII VI V, IVYVI VI h/VIIV IIIy, VVIIV IIIVII VI YVyVIq II VI I, etc.): Privy(locate on site plan): Materials of construction: V------ ------- Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): �\ toommonweakh of iviassacnuseuz = Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 8/15/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) at least two permanent reference landmarks or benchmarks. Locate all wells within100 feet Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® dravAng attached separately t5ins-0414a Tithe 5 Offhal fncredion Fem!:Subsurface Sewace Disngsal System•Page 15 of 17 1 \ %-+OmmO"Wealifl vi 1Y1a35acnu5e1X5 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 1575 OLD STAGE RD NAUGHTON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 /11 every page. 6tyrrown Dat eof State Zip Code Date of Inspection D. System Information (cont.) ® Check Slope ® Surface water (QI Check cellar ® Shaflow wells Estimated depth to high ground water: AT LEAST 5 FT feet Please indicate all methods used to determine the high ground water elevation: L I vbialned horn sysrern destyn Pians on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) rl rhecked vvifh Incal Ronrd of Hpnlfh-Qznlain- ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: REQUIRED BY CURRENT CODE uc7iic 7iiiiy ii ib iiwYcGr.iiii i�cMvi 7ii;wac boc i�c Yva i✓vTiYicwica�vic�niiaa vi icwi 7ayo. t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 l %ommonweakn of -- �0 massacnusens AMMM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1575 OLD STAGE RD PrnnPrty ArMrp�a NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 8/15/11 evert page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist jbj inbPt:Uuun Suiinnaiy.i1, o, i.;, i.i, Ui C Ulluumdu ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater 71 Sketch of Spwanp I?isnnsa!System pithpr drnmm nn pane 15 nr attached in serarntp file Assessipg As-Built Cards Page 1 of 1 TOWN OF BARNSTABLE LOCATION �r7S l� �T � �,a SEWAGE it Oyu•�� IC.r/ -//1 11U Ul.iUUVa�'J l/lfyt (]( IAl\lrj�L �2 _ ^� w J/ Vv v vvr INSTALLERS NAME&PHONE NO.(:7'J,-J� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) / d (sue) �3>r;=; ,'—;t OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Private Water Supply Well and Leaching Facility(If any wells exist �I 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) i Feet FURNISHED BY� /h► ���Q4E`!/� 3 - i ittp://town.bamstable.ma.us/Assessing/fWdisplay.asp?mappar=151008001&seq=1 8/12/2011 TOWN OF BARNSTABLE LOCATION SEWAGE ` VILLAGE i /� ASSESSOR'S MAP&PARCEL /-5`1 ®O d' ®rJ� INSTALLERS NAME&PHONE NO.�I-") SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 3 1 NO.OF BEDROOMS 3 OWNER PERMIT DATE: 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) J Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 46 3 tit, e .x . ;l ol No. 4/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for �Dioaal .paem Con0tructiou Permit Application for a Permit to Construct( ) Repair W Upgrade( ) Abandon( ) El Complete System rL✓f Individual Components Location Address or Lot No. %' �®�6 .P 9 e4; t 4E2 Owner's Name,Address;and Tel.No. Asse3sor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. COW Type of Building: Dwelling No.of Bedrooms 3 n Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building � ✓ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 'eQ gpd Design flow provided gpd Plan Date "�o—G'7 Number of sheets Revision Date Title Size of Septic Tank X�d'r�FC9 Jy 7,9 �' Type of S.A.S. Description of Soil 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo of Health. Signed dDate o�� Application Approved bZM,11 - 7 Date Application Disapproved by: Date for the following reasons Permit No. Date Issued 4'lr J, r �qlNo. ? Fee THE .0 MONWEALTH OF MASSACHUSETTS Entered in computer: _� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yet 2pplication for �Digo!6al *p!6tem Congtructton Permit Application for a Permit to Construct O Repair Upgrade O Abandon O ❑Complete System 4R J Individual Components Location Address or Lot No.,/S f'Olf� ,P76� "GPe2 Owner's Name,Address,and Tel.No. `� Assessor's MapMarcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 4 Dwelling No. Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) 1 Other Fixtures ' Design Flow(min.required) 0 gpd Design flow provided gpd Plan Date ,,9 `�/o—a,> Number of sheets Revision Date Title Size of Septic Tank Grx�!'J'�p,+ /Ooo. �' T pe of S.A.S. Description of Soil .a hNature 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 Environmental Code and not to place the system in.operation until a Certificate of Com-iliance has been issued by this Bo of Health. , S Sig I Date Application Approved 2 Date ` Application Disapproved by: f ` Date for the following reasons Permit No. «�+� Date Issued r THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS 4 Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System?Constructed ( �' ) Repaired Upgraded ( ) Abandoned( )by ��J! at 1 7 t O:Z.Q f r��g Q .00e1,424— has been constructeo in accordance j "with the provisions of Title 5 and the for Disposal System Construction Permit No. r dated.- Installer Designer ,00,/,O �'�`� #bedrooms Approved design flow gpd The issuance o this e it shall not be construed as a guarantee that the system unction as design U. j Date Inspector ——— — — -- — — —/ ------- � l No. — --_ ------.-- -- -- ----- _ Fee ��� P__THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS xis;po$ar 6p!gtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( /-*r Upgrade ( ) Abandon ) i System located at JS" �s O-�.6 P?A.r,-ems APO. A and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must b complffted within three years of the date of thi �eit.,�A Date / Approved by Town of Barnstable Regulatory Service . Thomas F.Geiler,Director ' Public Health DhiyWon Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: �� 1 ��ICO-7 Designer: -Dwy , ✓ Installer: "j I � Address: . Address: 1 � On-I Lf'W `' was issued a permit to install a (da ) (installer) septic system at i/� 0 based on a design drawn by (address) dated lilt? 10-7 (designer) -I certify that-the septic system referenced above was installed substantially according to the design, Winch may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. _ I certify that the septic system referenced above was mstalled with mgor changes (Le. greater fi m IW lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in a«wrdame with State"&Local plaa revision or certified as-built by designer to followA A 10 VI PLEASE RETUM TO BARNSTABLE PUBLIC REA I DIVISION. CERTIFICAI'B OF C0MPLL4NCE WILL NOT BE ISSUED UNTIL BOTH-THtS FORM AND AS- BUILT CARD ARE BY THE-BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU Q:HealWeptidDeaigaerCatWeadon Form Town of Barnstable P# llqg3 Department of Regullatory Services b Public Health Division Date � 200 Main Street,Hyannis MA 02601 tb tom'' , ` ;y/� • Date Scheduled ime Fee Pd. (� Soil Suitability Ass ssment for Sewage Disposal Performed By: C%`��1� LJ, Witnessed BrL'� z i Pi i 4 tDj LOCATION& GENERAL INFORMATION e n ley Location Address�j��� 0 fr AJ)d�/�� ,���/�f/leer's Name / ��/ //�A�/`� i NV®+64.�'�—J�/ u Address V 1/' 1 Cam-/ Assessor's Map/Parcel: /,51 © � Engineer's Name 40A E1/0 1".4 A7 R Jr, NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) �v Surface Stones IVA -e Distances from:',Open Water Body ft Possible Wet Area /�ft Drinking Water Well AM ft Drainage Way ft Property Line, 6 ft Other' , ft SKETCH:(Street name,dimensions of lot,exact locations of test holes Ac perc tests,locate wetlands in proximity to holes) r-aa-) C7 b co ry 419 Parent material(geologic) ko Depth to Sedroc ' IOU Depth to Groundwater. Standing Water in Hole: V'1T`' Weeping from Pit Face Estimated Seasonal High Groundwater r•� DETERMINATION FOR SEAS NAL HIGH WATER TABLE Method Used: �{ Depth Observed standing in obs.hole: in. Depth to Soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. index Well# Reading Date: Index Well level�— Adl.thctor _ Adj.Groundwater Level PERCOLATION TEST Dutp. . Time. Observation Hole# Time at 0" - Depth of Perc Time at 6" Start Pre-soak Time @ 7ime(9"-6") End Pre-soak M141 Rate MinJluch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICtPERCFORM.DOC DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gvel b-- 0 h fL (t L, /b J- 2 ' 719, el ktel& w 76 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.% z x�o •ems �� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, i 'f Flood Insurance Rate Map: ' a d Above 500 year flood boundary No— Yes Within 500 year boundary No✓ Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring!Pervious Material Does at least four feet of naturally occurring pervio s a al exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pery ous material? Certification - - I certify that on !v (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 required training,experti nd a er'ence described in 310 CNR 15.017. j Signature Date r 7 Q:\SEP110PERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF LNVIRONMENTAL PROTECTIO RECEIVED 7 AUG 2 0 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM I f PART A CERTIFICATION MAP ` S j mow Property Address: 1575 Old Stage Road West Barnstable MA 02668 PARCEL 1 Owner's Name: George and Gina Uribazo i r)T ,Owner's Address: same Date of Inspection:August 13,2002 Name of Inspector: Patrick M O'Connell Company Name: Septic Inspection Services Co. Mailing Address: 189 Cammett Road Marston Mills MA 02648 Telephone Number: (508)428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15-W of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority �l:ails Inspector's Signaturee n Date: 8 �J� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board ofHealth or DEP)within 30 days of completing this inspection.If the system is a shared system or has a deign 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. 'Votes 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. Page 2 of i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1575 Old Stage Road West Barnstable Ma. 02668 Owner. George and Gina Uribazo Date of Inspection: August 13,2002 Inspection Summary: Cheek AAC D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CM R 15.303 or in 310 CN+IR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfihration 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 ofHeahh. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): E 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 r ND explain: Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1575 Old Stage Road West Barnstable Ma 02668 Owner: George and Gina Uribazo Date of Inspection:August 13,2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require firrther 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—MN1)(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 fed of a surface water Cesspool or privy is within 50 fed of a bordering vegetated wetland or a salt marsh 2. System wi0 fad 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 wells*.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1575 Old Stage Road West Barnstable Ma.02668 Owner:George and Gina Uribazo Date of Inspection:August 13,2002 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool —X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or spool X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'A day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. - X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface — water supply. _ _X Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 1.5,000 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. Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1575 Old Stage Rd West Barnstable Ma.02668 Owner. George and Gina Ur ibazo Date of Inspection:August 13,2002 Check if the following have been done. You most indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X_ _ Existing information.For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1575 Old Stage Road West Barnstable Ma.02668 Owner,George and Gina Uribazo Date of Inspection:August 13,2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3_ Number of bedrooms(actual): 3_ DESIGN How based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents:_3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 236 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):_ 'pion-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Homeowner 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: Scheduled maintenance TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool —Privy no_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 1991 Were sewage odors detected when arriving at the site(yes or no): no r • Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1575 Old Stage Road West Barnstable Ma.02668 Owner.George and Gina Uribazo Date of Inspection:August 13,2002 BUILDING SEWER(locate on site plan) Depth below grade: 8' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_10' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 8' Material of construction:— _ X— — — concrete metal fiberglass polyethylene other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 4.5'X 8' Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: stick with hinge flap Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Homeowners have had tank pumped every 24 months. Baffles clear of buildup.H-20 components in good condition. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:—concrete metal— fiberglass—polyethylene other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1575 Old Stage Road West Barnstable Ma.02668 Owner: George and Gina Uribazo Date of Inspeetion:August 13.2002 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of lase pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X (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 outt of box,etc.): Box is level and no leaks. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Page 9 of l l PART C SYSTEM INFORMATION(continued) Property Address: 1575 Old Stage Road West Barnstable M9.02"S Owner. George and Gina Uribazo Date of Inspection: August 13,2002 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number:—I— leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Typetname of technology.- Comments(note condition of soil,signs of hydraulic Failure,level of ponding,damp soil,condition of vegetation, etc.): 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 or no): 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_): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS I Page 10 of l l PART C SYSTEM INFORMATION(continued) Property Address: 1575 Old Stage Road West Barnstable Ma.02668 Owner: George and Gina Uribazo Date of Inspection: August 13,2002 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. 1515 ZZ z3 5" `q-5' y3 94 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS i Page l l of l l PART C SYSTEM INFORMATION(continued) Property Address: 1575 Old Stage Road West Barnstable Ma.02668 Owner. George and Gina Uribazo Date of Inspection: August 13,2002 SITE EXAM Stope Surface water Check cellar Shallow wells Estimated depth to ground water More than 12 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-expWn: You must describe how you established the high ground water elevation: Site plans on record with deep hole logs show no water at el. 117 bat.leach pit eL 122. �I 1 5 4M, 'Lot NO. : ' r ADDRESS: `OWNERS NMI SEWAGE PERMIT NO. : _�(. NEW: REPAIR: DATE ISSUED: DATE INSTALLED: qI b INSTALLERS NAME: (D" , �I) INSTALLATION OF:j0MCtjaL MA WATER TABLE: FINAL INSPECTION BY: DRAWING. OF INSTALLATION ON REVERSE SIDE: - - - i, 43 f.# a�q op TOWN OF BARNSTABLE LOCATION SEWAGE # * VILLAGE ASSESSOR'S MAP & LOT0,0c INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ASSESSORS MAP : TEST HOLE LOGS � NOTES: PARCEL: LU I - c� FLOOD ZONE: SO I L EVALUATOR: ! AYE . M'� .� �L. � Ur`= � � � DATE: ��� � ��( � 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: - ' Ai�O �6 WITNESS :E: �� Health Regulations. 1 2 The installer shall verify the location of utilities sewer inverts and septic QVE PERCOLATION RATE: � It'1 r ) Y p components prior to installation and setting base elevations. ; 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot. The first two feet out of the d-box to the leaching shall be level. - r op-�-11(l 4) This plan is not to be utilized for property line determination nor any other •ldt A� o b 9p ta•�n r �► ,i9 purpose other than the proposed system installation. a /x 5) All septic components must meet Title V specifications. ZICWAY�0 7 d 6) Parking shall not be constructed over H10 septic components. LOCATION MAP Z4 Lam Zf R Lo ,� 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of five '41�vo `l payment for the plan and installation based on the plan shall be deemed / FiwE approval of the design flow by the owner. G/ 2,SY7� 9) The existing leaching or cesspools shall be pumped and filled with material if ' V per Title V abandonment procedures. Those within the proposed SAS shall be 'b 141 1 removed along with contaminated soil and replaced with clean washed sand . LAgrE.(1, per Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPT I C SYSTEM DESIGN applicable. 1) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE -0 owner to ensure such. ' 12)The installer is to take caution in excavation around the gas line if applicable. _ 2 13)The installer shall verify the location, quantity and elevation of the sewer lines V BEDROOMS AT �lQ GAL/DAY/BEDROOM -c3GAL/DAY exiting the dwelling prior to the installation. SEPTIC TANK 350 CAL/DAY x 2 DAYS - � GAL ECG - ' �`�' -USE �'CALLON SEPTIC TANK C �(15?11�1(� kZo'TtC- _ Ion y� no V01 L /y ( c� / �s/irl t 41 �.fV C J(2 A/c/ pUAf r t c..��_ �,IBSORPT I ON SYSTEM _�. _. _._ -- `� WA' o t SIDE AREA: X �C - 01 ! g {4 t __ ii4 ;.r-� % 1►� �,'� /� BOTTOM AREA: 2 ' 13 X C'��-1 - 2�L� � e / E P T I C SYSTEM SECT I ON 13Z t 3 .C) _ r• 6, MIA be 127-52Z`v s-rt !' - Coe. icTi2l G '3a►' X rL i 1� D BOX 12G,5160 r , 1 tom) Imo :I • b•� GAL 12�1�!! ► 2 l- -- - 124-. -7/1-2DSEPTiC TANK - _`_ _. �'-_t.��.'' _7D ��- _.W►�SN D_3 W�.. �01TDf'l C)5 '4f� Yt)l.G F'L cv- i o SITE AND SEWAGE PLAN ( a \ e o)-� - po i.n LOCAT I ON : PREPARED FOR : �IE.ZOI OF SEMC I W uA Q�1 s iv11� SCALE• o DAV I D B . MASON, DATE: 10 0 DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA W DATE HEALTH AGENT ( SQ$ ) 833- 2177 3 W Z w DENOTES PROP05ED WATER SERVICE ' i \ / ✓ \ 140.3 PROPOSED SPOT ELEVATION OPEN SPACE y i 162-- RECONSTRUCTION '. .\ \ \ 164 OLD STAGE ROAD 160- i \ \ \ A9 158 ` 162 / 7S 154. 160 746 OPEN SPACE 1 44. 1 .3 \ \ \ g } 140 R , , OPEN SPACE 1 „ \ 54 D � 40.1 7 ._ 6 139.7 \ �34 PNR OSED \ \ >z 732 � � HOUSE \ �, �• — : \ _ \ \ , OSE — 15 ROP \ \ 0 '3 P Y � I LOT 1 p \ RIVW A \ 32,160 ±S.F. 139.5 \ IN, \. ` i — —148 \ \ 00 GAL. _ 14 w PTIC \ \ \ D OX \ _ - -- 1 46 � ►mot \ \ _ \ i iRESER 167.25 - POLE 117 46 r _ 144 \ — \ ` 6' DIA.x 6' DEEP V, \ 127.t LEACHING PIT WIT \ IN, _ ' a a \ 8 2 OF STONE ALL a > A -142 AROUND 0 - — �Q OPEN SPACE 1 S / T o , . 4 POLE 118 DATE7 DESCRIPTION jDrawn hecked LL - ry R E V I S I O N S PLOT PLAN PREPARED FOR . ry GEORGE AND GINA URIBAZO NOTES POLE118S 51_8-, BARNSTABLE 1. ASSESSORS NUMBER 1 MARSTONS MILLS MASS. 2. ZONING DISTRICT RF 3. FLOOD HAZARD ZONE C =0f.� SCALE: 1,, 20) DATE: JUNE27, 1991 Mq 4. TOPOGRAPHY COMPILED FROM AN ON THE GROUND INSRUMENT SURVEY PERFORMED IN � ti holmes and me rath inc. 1985.. ELEVATIONS ARE BASED ON THE NATIONAL GEODETIC VERTICAL DATUM MicHAE� g • " OF LAND PREPARED FOR FIRST OLD STAGE TRUST DATED MARCH 27,1986 . a � E � civil ..engineers and land ;surveyors 5. REFERENCE. SUBDIVISION PLAN 200 5054 main street No. � c R faimouth ma. `. 02540 r ST NAL �� DRAWN: MJB CHECKED: . 91092 W 53-2-12 - SHEET 1 of 2 JOB `N0. DWG. NO.. SOIL TEST Finish grade above and adjacent to system shall slope away at a min. of 27a Date of soil test: JUNE 6,1986 4" diam. cast iron or Schedule 40 PVC pipe (tight Joints). Test taken by. BRIAN DUDLEY 20' min. distance (building to edge of leaching system) Results witnessed by. T. MCKEON Percolation rate: 2 min./inch 10' min. dist. GENERAL NOTES Ground water was not encountered. 1) No change to this system shall be made unless First floor elev. = 141.8C approved in writing by holmes and mcgrath, Inc. SOIL LOG Removable covers within 2) Subject to inspection during construction by the 12 of finished grade Board of Health and holmes and mcgrath, Inc. NO 1 S = .04 Dist. box 3) Heavy construction equipment shall not travel over disposal system during or after construction. DEPTHI SOILS ELEV. emova a cover 12" min. cover - S=0.287 5.5 t f Clean backfill 4) Disposal system to be constructed in accordance 0 129.5 Foundation over tank 2 with Title 5 of the State Environmental Code. design level 2" layer of T/8 to 1/2 5) A copy of these plans'must be kept on the site TOP, by others u eve o000o washed' stone during the time of construction. SUBSOIL S 0.08 °oEo�° _ C c o 6) A copy of these plans must be furnished to the 2.0 127.5 cc r O O m � .� c o o contractor constructing the disposal system. o SEPTIC TANK ao ao o o 0 7) Before backfilling, the contractor shall notify "� ai ai ai +' N Precast c o - MEDIUM 100, GAL. _N �' '� c v o holmes and mcgrath, inc., or the Board of Health II p II vi w concrete c e o SAND II >_ c t o Agent to inspect the system as constructed. 5 II _ � Teaching c 9) 0 12.0 117.5 r 8) If the contractor encounters any variation between Pit c3v0 The contractor shall excavate the existing conditions shown on the plan and the m c > °c m c0°o°0 Elev.=122.00 5 feet below the bottom of the conditions encountered on the site, or any soil o Ac c c condition different than shown on the soil log, or 5 H-20 LOADING r s' 2' proposed Townlofching Barnstableit and Boaonotact any adverse soil, the contractor shall immediately c diameter contact holmes and mcgrath, inc. Holmes and — of Health to inspect the soils mcgrath, Inc. will examine the soil condition Design Criteria ` ._.�.' g P Y 9g Not to Scale H-20 �LQADING prior to installing the leaching and report to the owner on suggested revisions 2 ft. of 3/4 to 1/2 washed stone Equivalent to 330 al.'s da all around precast pit, providing an Number of bedrooms: 3 E q 9 / Y effective diameter of 10 ft. Garbage disposal unit: No Leaching area - capacity required: 330 gal.'s/day Side area proposed: 172 sq. ft. Bottom area proposed: 78 sq. ft. Total area proposed: 250 sq. -ft. Proposed leaching capacity. 508 gal.'s/day Water supply. Town Precast concrete units: H-20 loading design 9'-0" T. ALL ACCESS MANHOLE COVERS FOR SEPTIC TANK, DISTRIBUTION BOX, AND LEACHING STRUCTURE SET MORE THAN 12" BELOW FINISHED GRADE, INLET OUTLET SHALL BE RAISED TO WITHIN 12" OF ,* FINISHED GRADE. I •� ALL OUTLET PIPES FROM THE ..z— SET LEVEL FOR. AT LEAST 2 FT. DISTRIBUTION BOX SHALL BE `':':.. :'.r ;r.r•T. : �. :•.;•. :. 21" CONCRETE COVER ' FRAME do COVER STEEL REINFORCED PRECAST CONCRETE OVER "T'S" WHERE REQUIRED. " 9 — 5" OUTLET PLAN V/�1 EW ; '�,, KNOCKOUTS DATE DESCRIPTION Drawn hecked PRECAST CONCRETE I 30" 28" INLET " TANK RISER WHERE OUTLETr2l, R E VSO N S g" 6 REQUIRED �\\ � 68 ..REMOVABLE COVERS , 4" ,. .a PLOT PLAN — DETAILS �. r 3" min. clearance required INLET 'T',' 30" " L8- INLET 4 PREPARED FOR 2" min. inlet to outlet 6" min ' ,D" mina OUTLET PLAN SECTION CROSS-SECTION GEOR GE AND GI N A U R I B AZ0 Liquid level E 0 cr 9 HOLE DISTRIBUTION BOX LOT 1 OLD STAGE ROAD io a Eo ? E o " o t_ I N _I ; ., NOT TO SCALE MARSTONS MILLS MASS. ��_ BARNSTABL.E, o 8.�ow, SCALE: AS SHOWN DATE: JUKE 27,1991 , 5' 3* * holmes and me rath, inc. MiC L g Ro. ILL civil engineers and land surveyors CROSS—SECTION END SECTION N 3, 54 200 main street TYPICAL 1000 GALLON SEPTIC TANK �t.' .TiR�G�� falmouth. ma. 02540 sS/pAiAL E� DRAWN: MJB CHECKED: ,491— NOT TO SCALE SHEET 2 of 2 JOB NO: 91092 DWG. NO.: 53-2-12 a