HomeMy WebLinkAbout0313 OST.-W.BARN. RD - Health r
313VOst-Wi
Mars_tori Mills
A = 121 — 144 - 001
No. U )L 0` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
2ppfieation for Disposal Opstem Construction Permit
Application for a Permit to Construct( ) Repair(-,,,,upgrade( ) Abandon( ) ❑Complete System [ idividual Components
Location Address or Lot No. 0` �l.'/ ' Owner's Name,Address,and Tel.No.
As essor's Map/Parcel Llb-( vt AyL e �/yto/A 1,
Installer's Name,Address,and Tel.No. 5D�.76 yr� Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures G
Design Flow(min.required) 41416 gpd Design flow provided �7`y(, gpd
Plan Date Number of sheets Revision Date
Title y
Size of Septic Tank ll3 Type of S.A.S. 6;4 CA,-f�"`hT�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) o'!^ C ��' c z"/dre6t
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 tem in operation until a Certificate of
Compliance has been issued by this Board of Hea
Sign Date �r 22
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
-- --------------------------------------------------_----- ------_- -_- ---
No. �� �0 t Fee,
i
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:=/
PUBLIC HEALTH;DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for Disposal 6pstem Construction 3permit
Application for a Permit to Construct( ) Repair(-*Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. r�' � 107' Owner's Name,Address,and Tel.No.
As essor's Map/Parcel � ��,—Ot1 -) ot
Installer's Name,Address,and Tel.No. jD�,�(V � � Designer's Name,Address,and.Tel.No.
f Type of Budding:
.Dwelling No.of Bedrooms "0'7 r Lot Size sq.ft. Garbage Grinder( )
1
Other' Type of Building No.of Persons Showers( ) Cafeteria
-Other Fixtures
Design Flow(min.required) ��� gpd Design flow provided �j`;/� gpd r
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank B `L2:� Type of S.A.S. � �
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) D — ;x,
Date last inspected:
-4
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 placet e.system in operation until a Certificate of
Compliance has been issued by this Board of Hea �, �r�°�" - t.. -
Signd--. /n _•�'" Date �~ 22
c�
Application Approved by � � 1 s,,,. Date
Application Disapproved by Date
for the following reasons
Permit No. 4-7 2 _U-71 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,� MASSACHUSETTS Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by is y, D j�"'—� bl e..,w
at d L /� �� /• /�/� has been constructed in accordance
r ��ii//�� f
with the provisions of Title 5 and the for Disposal System Construction Permit No. )04-. 0 7.ydated 31/�
Installer of o+ ,r/� _ Designer
#bedrooms / Sn
Approved design flow
pp $ ,1 014' d
gP
The issuance of this permit shall not be construed as a guarantee that the system willf functtiion/as designed. f
Date 17 3,.) Inspector
---
No.
- -- -- - -- ---•-- ---- --- ---- -- --- -- - -
Fee -
THE COMMONWEALTH OF MASSACHUSETTS
p PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Vermit
Permission is hereby granted to Construct ) Repair( Y� Upgrade( ) Abandon( )
System located at �J Lo E /l F� _ MAI
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. 4
Provided:Construction must,be completed within three years of the date of this permit.
Date �( r J/ •2- Approved by
.. /ilq-0ol
Cofnmonwealth of Massachusetts
Title 5 Official Inspection Form
INA
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
m.y
313 Osterville West Barnstable Road
G^M
Property Address
Barbara Breen `
Owner Owner's Name "7
information is :
req u i red fo r eve ry Marston Mills MA 02648 9-28-17y
page. City/Town State Zip Code Date of Inspection K
r<,w
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms �( r oZ 0&^ �tpllt}111py�j�
on the computer, jNUFS6i����
use only the tab 1. Inspector:
key to move your =
cursor-do not James JAMES N
James D.Sears ;m
use the return Name of Inspector 's 0
SEARS :-4
key.
Capewide Enterprises;•. �_
Company Name %� FRTIF� .•:����
153 Commercial Street �ii,F 5�I N
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
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 Evaluation by the Local Approving Authority
UW41V-94, 9-28-17
I ector'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 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.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'•Page 1 of 17
j�o
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
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:
The system is a 1000 Gal. Tank D Box and pit.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
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.
9. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M ,• 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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 is less than 6" below invert or available volume is less
El ® than '/2 day flow P/T
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must'serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 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.
15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
1000 Gal. Tank D Box and pit.
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2015 = 0
9 ( Y 9 (gPd)) 2016 = 0
Detail:
Sump pump? ❑ Yes ® No
Last date of occupan NAcy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
i
Water meter readings, if available:
t5ins.doc•rev.6116 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
313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. Cityrrown 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: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1990 Permit # 89 -542.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 32"
feet
Material of construction:
❑ cast iron N 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 21"
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. Precast H - 10
Sludge depth:
1"
Gins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
L
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt- Plan -TapeSldge Judge
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 at working level. Tank and cover's 21" below grade. inlet tee, outlet baffle. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
requiratifo is Marston Mills MA 02648 9-28-17
required for every
page. Citylrown 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 O
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 16"x 16"-30 below grade. Box is clean and solid w/one line out. No sign of over loading or
solid carry over.
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:
;5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
f
Commonwealth of Massachusetts
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M ,•''� 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. precast pit w/3' stone. Pit at 38" below grade w/cover at 18". Pit is dry
w/stain line at 20". No sign of over loading or solid carry over. No hign stain line.
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
-5ins.doc•rev.6/16 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _
°M 313 Osterville West Barnstable Road
Property Address
Barbara(Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
page. CityTTown 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.):
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is required for every Marston Mills MA 02648 9-28-17
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
otiT
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A
03 ,
03-9 34 -S
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Sins.doc-rev.6/16 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 313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
requir required
is Marston Mills MA 02648 9-28-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Nv
Estimated depth to igh ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
.Auger T.H. at 14' below grade, no G.W.. Bottom of pit at 9' below grade. Bottom of pit at 5'above
T.H. Depth.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
:5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
I
Commonwealth of Massachusetts
9-2
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
313 Osterville West Barnstable Road
Property Address
Barbara Breen
Owner Owner's Name
information is recuired for every Marston Mills MA 02648 9-28-17
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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LO-"AT10N SEWAGE #
VILLAGE: ASSESSOR'S MAP & LOT/a/-
1NSTALLER.'S NAME & PHONE NO. ]L� riDD '-
SEPTIC TANK CAPACITY Z&?g (g�
LEACHING FACILITY:(type)_ ,��,a�
NO. OF BE.DROOMS__� PRIVATE WELL OR UBLIC WATER _
BUILDER OR OWNER�;r. o,r� ��'iL iV_
DATE PERMIT ISSUED:_�� -q _�
DATE COMPLIANCE ISSUED.
�� " ----
VARIANCE GRANTED: Yes No __�
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
4_W,-J..............oF......�3 f�t�,J �A L t(
Appliration for Uhipwia1 Works Tonstrnrtinn rumit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
ear 39 �SrE�z�se �f _ r3/�i2�vs ,�/� rt>� . ��J'`4S
..........-•-•• ..... .•• -•••...............�......._....... ... �_......_......_.._.....----• -- - --•- ....---_
.........
.--•-
Location-Address v or Lot \o.
.....
- -�� -------�. •-•--....�..................•......---•-•------....--
Owner Address
a ----- P 21 s c.0 L t a S A..e/
-- ---------
Installer Address a
d Type of Building Size Lot_.__.----'------------------Sq. feet
Dwelling—No. of Bedrooms....................__..._...__.._....__....Expansion Attic (N) Garbage Grinder (" )
a Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures ---------------------------------------•------
W
Design Flow..............`6...........--._._..._..gallons per person per day. Total daily flow_---__--3_3.b_.._.__._...._...........gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by--------- A _r.fit......_ ._..."..� .......................................... Date----
Test Pit No. 1.. __ ...minutes per inch Depth of Test Pit...!t.....__.. Depth to ground water....N. ..___..__.
104 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�NSE [ �r�1G0M SoM � ma� n ...
.................................••--- -----••----••
---..
Description of Soil ............. ....1!. -••-------•---•-••--------•-----•-•--•-•.........••----.
---------------- ----
x
U •••••.
W
--------------------------------------------------------•-----------------------------------------------------------•------------------------------------------•-----------•--•-••----• --•---•---••---
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
-------------------------------------------------------------------------------------••--••..-•••-••-•---•••-•----------•-•-----•......----•--•----......•--• .........................................
Agreement:
The undersigned agrees to install the aforedescribed I ividual Sewage Disposal System in accordance with
'TT
"IT PIs-.�
the provisions of :11 5 of the State Sanitary Code— T e ndersigned further agrees not to place the system in
operation until a Certificate of Compliance has a issu b t e board of lth.
Signed•••V.-�. ---.... " ®®.F.....L D1�•/•-
Date
Application Approved By............. -- . .� . . .. .,----- --•---••-•--------------------------•--- --•-----
Date
Application Disapproved for the following reasons:................................................................................................................
.........-•---•-------------------•---------•------••----•---•--------•--•----•--•-................:: =-•-••-•---------•-•-----------•-------•----•------•••-••-•-••••••........-•-•-•--•--•-•.......--
-• - Date
Permit No..........P.._ .....5_.Y.`:'----------------- Issued.......................................................
D:.te
r y ,
h No.. x _ FEs.....a.._ ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------� ..............OF..........................................................................................
Appliration for Disposal Works Tons rnrtion Prrmit
Application is hereby made for a Permit to Construct ( V) or Repair ( ) an Individual Sewage Disposal
System at
39
... _ .................... ...................................................... ......•-.......................................
Location-Address or Lot No.
.... ` "�........�� � ?' l�` -° •--•-•... ............_........------ a (v -
_ Owner Address
C 6 E.C, Q 5 0 A
........... ........•---••--------.....------............•................. ...-•••••-••-••--•-•------••-•---••-------••--•--••-•---•--•-••-••-.................----------•-•.
Installer Address
QType of Building Size Lot-----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (i ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
04 Other fixtures ------------••-•••.............• -
W Design Flow..............57--5_.......................gallons per person per day. Total daily flow........ -"__ .........::..............gallons.
1:4 Septic Tank—Liquid*capacity...._.......gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-•--__..-__--_______ Depth below inlet.................... Total leaching area....--------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
.fle'� ...��' _.._.___ �� ....
,aa Test Pit No. I..` . __-_minutes per inch Depth of Test Pit .f.��.e. ...... Depth to ground water------------------------
Test
fi Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----__-___---_--_-____.
a' -----------------•-------.------
O Description of Soil......... - ca�a r S r r+� ._...__
x
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•......••....._..........
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
--------------------------------------------------------------------------------------•--------------------------------------•••-----••-•--••••-••-•-----•----•-----•-•-•---•-•---••••••....--•--•--•-•-
Agreement:
The undersigned agrees to install the aforedescribed Idividual Sewage Disposal System in accordance with
the provisions of 11:!.l. 5 of the State Sanitary Code- Tale undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b&e issQd by,t�e board o:�health.
Signed .. Y ... .. --•---------------------
- t _..._
r �. Date
Application Approved BY �Y,.. c.�,. _�
j - r'Eate v
,C - 5 c i_ 1
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------•--------
-•-•...-•••.................•••-••----•-•-•••••••-•-•-•-.._....•-••••-•-•-----•-.......•--•-•-•---...-•----•----•••--•••-•---••••••••••••••••--••••••••--------.._..-•-•••............--•.........------
Date
Permit No.-••-•-•. l*_ ...._...... Issued----------------
. '--- ---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........?..`.".......................OF............. . .... ...............................................t.
%pEntifiratr of TuntpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
-----------•---------------••---...------------------------------.............---•----------.....-----------............---•----•--•------.--
.Y1
.s y k [ 4 3 -Installer '
at--••••••.............•............................ -- --.---... ...-- --------.......--•-•-......•--•-• -•--•J -..---•- -------- --------------..........s -----
has been installed in accordance with the provisions of T I T IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.........5%�-..yam__S�......... dated-..............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................. ... Inspector..............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i�a ! ......................OF..........:......•.-............_ ...........
`i:.. 6f ... FEE......
Disposal Works C�nntrnrtion Prrmit
Permission is hereby granted_.__. __. •:-----. '- '.'`... _ `
to Construct (V ) or,Repair ( ) an Individual Sewage Disposal System A �
at No. `�� ?5.ry_cPa to --t •--------- ------- ....... . -------- --....._ .......------......----------------------�.5 .
----- --------
Street
as shown on the application for Disposal Works Construction Per it N Da
ate d
• . .
Hh ..............
----••----------------- ---- )------------ ---
- ---•-•----•---------.-.-.-.-.-----Boar
.
DATE............. -----•-••..............•------------
d ea
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
a
• h
0 D
NOTES. MARSTONS MILLS
t - o
AL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.Q.E
20' MINIMUM OR AS INDICATED ON PLAN 1. L
TITLE 5 THE TOWN OF B aN3-TAELE RULES AND ,�� s
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE;' LOCUS ?�
to IN. AND THE REQUIREMENTS OF THIS PLAN. m�
10 MINIMUM 2. ALL COVERS TO SANITARY 'UNITS SHALL BE BROUGHT TO
ROUTE 28 ROUTE 28
T.O. FOUNDATION e' MIN. ,— ; CLACKFILL
EAN SANDTM 0WITHIN 12 OF FINISHED GRADE. LANE
53. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE
f MASONRY SHALL BE MORTARED IN PLACE.SI
4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE
PITCH 4• SCH. 40 Pvc PIPE - OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR
1/4' PER FT. MIN. PITCH 1/8' PER N
3 MIN. r LAYER WITHIN 14 FT. OF DRIVES OR PARKING AREAS. H--20 LOADING
Flow Ln+e 1/e' - 1/2• SHALL BE USED UNDER OR WITHtN 10 FT: OF DRIVES OR
10 . WASHED STONE PARKING.
6 r M� . LEVEL S. NaT A PP1.►CA G L.E o
4'-0* '> . 3 4' — 1 1/2'
UQLqD
LEVELDISTRIBUTION ' � ' STONE 6. EFFLUENT`PIPING FROM DISTRIBUTION 'BOX SHALL ENTER LEACH PIT
BOX THROUGH SIDEWALL OR TOP >ONLY. ENTRANCE THROUGH MASONRY LOCATION MAP
� 53.E
EXTENSION WILL NOT BE ALLOWED.
0-0 7. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED
Ia cAt.�aN sEP�c TANK � L I -� RESTRICTIONS OR ZONING REGULATIONS. OWNER/APPLICANT SHALL
OBTAIN SUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY.
SEWAGE DISP�IST T SYSTEM PROFILE BOTTOM OF TEST HOLE 9 8. HORIZONTAL AND VERTICAL CONTROL,' SEE LEVY, ELDREDGE
NOT TO SCALE
OR USGS PROBABLE NIGH WATER LEVEL k WAGNER FIELD NOTEBOOK # ,
_ DESIGN CALCULATIONS
CURRENT ZONING INTERPRETATION:
-MIN. FRONT SETBACK _gip FEET 1 NUMBER OF BEDROOMS r
t.
MIN. SIDE SETBACK I5 FEET GARBAGE DISPOSAL UNIT ucw!
w t TOTAL ESTIMATED FLOW ,
4 MIN. REAR SETBACK FEET 33a
( 110 GAL./BR./DAY, X BR.) GAL. /DAY
REQUIRED SEPTIC TANK CAPACITY GAL.
ACTUAL SIZE OF SEPTIC TANK 1�GAL.
�pl LEACHING AREA REQUIREMENTS
SIDEWALL AREA 2,5 GAL./S.F.
� P'rI�COLATION SOIL TEST
BOTTOM AREA 1.0 GAL./S.F.
Q LEACHING CAPACITY (BOTTOM + SIDEWALL) GAL.
z
a c Cn 2 7T /ZZ 2 2.5 +7T 14 2 1.0 GAL.
f�l � y DATE OF SOIL TEST ` �� �` ( � )( � )( ) ( / ) ( )
1 �+ : •r�} G ` 'wi E7`�2 JVLL:.J/Cw?: CAPACITY
WITNESSED BY , ,. � ., 1=C7 �,4.N _ . RESERVE.. LEACHING
�c>T 4Q i E
,� SAME
f PERCOLATION RATE Z MIN:" INCH �x.^ 2
OBSERVATION HOLE 1
OBSERVATION HOLE 2
v V.= - ELEV.=
BREAKOUT CALCULATION:
p --
!� XJ O - 67ra o f
LEGEND:
EXISTING SPOT ELEVATION 00 0
\ - X
UR--------00---
EXISTING CONTOUR
ON 00.0
FINAL SPOT ELEVATI
FINAL CONTOUR
WRIER AT ELEV..
WATER AT ELEV.
SOIL TEST PIT LOCATION
1► ► ' ) , (ct 'G TOWN WATER W W
SEPTIC TANK C7
DISTRIBUTION BOX ❑
l L WATER LEVEL ADJUSTMENT: /F
z?Z SF t ' PRIMARY LEACHING PIT O
LOr 2-0 � � � RESERVE LEACHING PIT
y TEST DATE WATER LEVEL
i I I G INDEX WELL
WATER LEVEL- RANGE ZONE -` 1 ta_Ix,_F3"� INITIAL ISSUE t �5
l ' DEPTH TO WATER LEVEL FOR INDEX WELL NO. DATE DESCRIPTION BY
r !
FOR THIS MONTH
WI v' WATER LEVEL ADJUSTMENT
SITE PLAN & SEPTIC DESIGN
►�/F Lt1AN',
l fl«t r ,� .1 DEPTH TO HIGH WATERUZ- .. S A Az RCw4D
IN
5 BARNSTABLE, MASSACHUSETTS
FOR
Oct�
�" `'r GREENBRIER DEVELOPMENT CO. INC,
PA LA.
` VY
APP-ROVED: ' BOARD OF HEALTH . 10 z y „ JOB NO. 1472
a SCALE: 1 = 40
_ M
SITE PLAN
v S LEVY, ELDREDGE & WAGNER ASSOCIATES INC.
DATE AGENT RNGIN�RS i,ANDSCAPI ARCfi1T M PLANM LAND OWYORS
889 WEST MAIN STREET CENTERVILLE MA 02632