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Home My WebLink About0364 OST.-W.BARN. RD - Health Marstons Mills A = 121 093 r 1� ► I rvR3 Commonwealth of Massachusetts (P Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <� 364 Osterville West Barnstable Rd. Property Address {. , Michael Benton 3 Owner Owner's Name information is arsons MillsMa 02648 1/12/2021 required for every M page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Impg out A. Inspector Information filling out formsms on the computer, Raymond Dumas use only the tab key to move your Name of Inspector cursor-do not Dumas Landscape Const. Inc. use the return Company Name key. 564 Old Stage Rd. ,Q Company Address Centerville, Ma. 02632 City/Town State Zip Code Rn 508-509-0210 S1437 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected-the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/12/2021 �Insp or' ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required forevery Marstons Mills Ma 02648 1/12/2021 page. City/Town State Zip Code Date of inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as _approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name required for is every Marstons Mills required for eve Ma 02648 1/12/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cons.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 18 f Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is,every Marstons Mills required for ere Ma 02648 1/12/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This asses system if the well Y p water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water P vY p e supply ❑ ® well. PP Y ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 5 of 18 I Commonwealth of Massachusetts 63 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were an of the system components pumped out in Y Y P p p the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 18 f Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .% 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 1000 gallon septic tank, D-Box and one 600 gallon leach pit Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No . Water meter readings, if available (last 2 years usage(gpd)): Detail: 2020 6000 gallons, 2019 0 gallons, 2018 12000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Occupied now Date t5insp.doc•rev.7/26/20161 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form '~ b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is every Marstons Mills required for eve Ma 02648 1/12/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information isequired for every MarstonS Mills Ma 02648 1/12/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1993 as per permit on file at Board of Health Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: approx 28 ft. feet Comments(on condition of joints, venting, evidence of leakage, etc.): good t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 18 Commonwealth of Massachusetts F Title 5 ,Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L.! 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank ilocate on site plan): Depth below grade: 2 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 gallon 8'6"x 4'10" Sludge depth: none all water Distance from top of sludge to bottom of outlet tee or baffle none Scum thickness none Distance from top 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? removed cover dip tank with stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): not needed at this time t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name rnquired for is Marstons Mills Ma 02648 1/12/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts (e Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y� 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. City/town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at level 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.): Inspected with camera from outlet tee on septic tank t5insp.doc•rev.7/2812 0 1 8 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Inspected with camera ,water level 42 inches below bottom of pipe Type: gallon ® leaching pits number: 1-600 g ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: pre cast t5insp.doc•rev.7r2W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owners Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): all good 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Cisterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I I t5insp.doc-rev.7/WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 L\ Commonwealth of Massachusetts - P Title 5 Official Inspection Form i Subsurface Sewage Disposal System o No t ot for Voluntary F� ry Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owners Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ® drawing attached separately ittins:' u aaP�a.tou:n:�f2>a xastable.us rXP trtments/Assessing,'T-roperty_. ' C`Wtll TOWN OP BARWTABLE LOCATION LOT #3 C��sm�-h- ... SEIVACE il VILLA OSTERVI G8 LLE ASSESSOR'S YAP& LOB'_aL INSTALLER'S NAME 6 PHONE NO.ELLIS BROTHERS CONST. CO 362-6237 SEPTIC TANK CAPACITY LEACMG FACILIZy.( ) L nos (sl�eD Y'7C� NQ.OF BEDROOMS__.Z,PRIVATR WELL OR PUBLIC VATER� f BUILDER OR OWNER I-/AM f31, DATE PERMIT,ISSUED; DATE COMPLIANCE ISSUED! vARIANCE GRANTED: -Yes 1 r i G.sr,4,rs� I r of Kbvs JL t5insp.doc-ray,7/2%201 e - Tfflx 5 Official inspeeticn Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check ec cellar ® Shallow wells Estimated depth to high ground water: 12 ft+ 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: no water at 144" per test hole on permit ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: bottom of pit 108"' no water at 144"as per test hole 4/8/1993 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7Y2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 364 Osterville West Barnstable Rd. Property Address Michael Benton Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/12/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist i Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 �l A , IfOV�TOWN OF BARNSTABLE LOCATION LOT #3 OAJ" W SEWAGE VILLAGE OSTERVILLE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ELLIS BROTHERS CONST. CO 362-6237 SEPTIC TANK CAPACITY /0'O6 LEACHING FACILITY:(type) e Q6 (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No s4Q 6TICL4 A r t5 e � a f 0 qq THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH ..... .. ..................0F............. ....Jf��......C............................... Appliraftan for Disposal Works Tons#rudiun ramd Application is hereby made for a Permit to Construct (r/) or Repair ( ) an Individual Sewage Disposal System at: ' J ✓�c ; W: Ff!U!sTi c f ............... ........................ ---.. . ..... ..»..........»��Locat •Address... ---•.............. ........... ....».or•Lot No...........-•-..»..-•-.»................ aer •Address a _.......---•--......•--... ....................................•-••......----....... ................................................... ....----•--------.... Installer Address Type of Building ..� Size Lot 2..�r .��_._�Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder Other—Type e of Building ............... No. of-persons Showers p., YP g -----•--•-•-- P ( ) — Cafeteria ( ) p' Other fixtures Design Flow................ . ............... lops per person r a . Totaly fl9w---..........2 -� . ..... 1Pns? W /� WSeptic Tank—Liquid ca.pacity........._. Ions Length... .L2:. Width..��...1�_. Diameter................ Depth.........__. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. /3 Seepage Pit No............ ....eiameter .!U........ ..... Depth below inlet.........`Y4....... Total leaching area_29C6 sq� « t.Other Distribution box (! Dosing tank ( CL p Percolation Test Results Performed by........._ c-J -. T v 9 ., . ---....... Date..... •••- Test Pit No. 1...:............minutes per inch Depth of Test Pit..../.�......._ Depth to ground water.....?/T�`... LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................. Depth to ground water........................ Qi It ............. •..... ---•-•.......................... ..If- �'�' ........ O Description of Soil..52.-.6.�....... .......... ...--..G ^ ,(� W _........ ---------- ----........ ----------------- •-------- -------------- ..--.--------------- -------------- .... ........................................................ ............... --------------------••-•--•-------------------------- --------------.-.-------•--•-.-.-•------------------------------ •------------------------- •----------••--••-•-•-•----------------- •••• V Nature of Repairs or Alterations—An 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 Sanitary Code he undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ed b the bo of ealth. Y ' Signed........................ �...`... ............. ..»':✓... • Date Application Approved BY ....._.. - Da Application Disapproved for the following reasons:.......................................................................................................... •••------------------•---................----...---...-------••-•••-----......-•----•••---•-•------...»..............---•---•------------•-•---......------------.....-•-----••-----•--•......---•---» Date PermitNo........ ' - ....--_.».... Issued......................................».-» ....» Date THE CoM�MONWEALTH OF MASSACHUSETTS y, BOARD OF HEALTH OF.. Appliratinn for Disposal Works Tonstrur#inn Frrmit Application is hereby made for a Permit to Construct ( �) or Repair ( ) an Individual Sewage Disposal System at• 1 _ r, J S4�'�rE' i j p Locati1q. on�-=Address or Lot No. ................«1«»JZ«.t«Jj�p. L1(...». `�.�I-,--•.-•----.- .....•............ ........------............•................ .......•..................•.«...»........._. Owner -V •Address ................f««('._«.......-.--.--.......... ..+�^y ..............-- -----.-----.................._-«............---.---................. .............•.......... Installer Address �"� / Type of Building ✓,,. " Size Lot........... _-:_'..`..__....Sq. feet g— ..............Expansion Attic ( ) Garbage Grinder ..� Dwelling No. of Bedrooms.............................. pay, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ................................... =°', "'. ...-:,..._.. Design Flow..................................:........gallons per person 'pe+r day. Total daily flow......................_.---.._...---.--....--gallons.. fl. �(' .. �7 CJ /r W Septic Tank—Liquid ca.pacity.....:._.__gallons Length____v.:._....... Width................ Diameter................ Depth_.___........._. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.....................Diameter.........('..... Depth below inlet.................. Total leaching area.::" "..G.sq:ft.' ' Z Other Distribution box Dosing tank aPercolation Test Results tr Performed by....... ''- ':`�c..," T�.`. ...-. Date.... j l 1-4 Test Pit No. I................minutes per inch Depth of Test Pit...._........ Depth to ground water....................... Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ = .::.......:.......: .......................... ... .......:-......------..._.........------•-•--•---------•-.._..•-- O Description of Soil.................�y. ' O FJTrS ! , ,�G, - v x C r., r --•--•----------------------------•---•--.....--•-•---.......------•--------------••-------........---...---------.....----------•----------••---- U �.. ------------------ ------------------- ----------------------- •...... --------------- ............................................................... UNature of Repairs or Alterations—Answer when applicable................................................................................................ -----•-•------•------------•-•--......-•----•................•-•-••-•-•-----•--.........-------•------•-•----•-------------------•--•---------.......--------•---.........-----..........-------•----•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code=•The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-issued by the board of health. fy l f Signed...................................................... ........ •-----..._.............. - ate A lica.tion A roved B +. r'r —% - 7 , } It Date Application Disapproved for the following reasons:---•------•-------------•--•--........--•----------•-•-------------•---•-----------------------.........--««« ......................................................... .•---- --•-•-----•-=------•-«----•--•---..«....._...--••-----•--...--•-------------•-..._...-----......-•--••---------------•--•---•-•-••- ate Permit No........ .'«o ._l..! _.......-«.«.... Issued............................................D ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF..................................................................................... (9rdifiratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................................�'''r"'c'c�a-----------------------------------------------------------------------------------------------------------------------------------------------_ fat..._..... t� ._ !'� �LG' Installer V�7fL- ---------- e with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......r..- .................�'..... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ ram DATE............................../----..---�----••----••---.........------.. Inspector........ZZI---!------------------------ ---•--------- ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD /OAF HEALTH ..........................................OF...... !' :..arc �..`F�Iv`� c ..........�..............:................................................... No.. D FEE..... ....--................... Disposal VoAg Tons#rurtion f rrmit _ .�� .. _ Permission is hereby granted.-------•--.... ...-•--•-. ---------•-------•................................................................... to Construct (�) or Repair ( ) an Individual Sewage Disposal,System at No............ L ' 7` _...5:�...............� `A- C='-='A=-' .. - I_,.- :'�."............t � ' ,.'.. ...._ as shown on the application for Disposal Works Construction Permit Street 2�1 Dated.._....:/.............. ,V \� .................. " - L DATE............... •-..= .... ....- ....._... Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS OfOmWN OF BARNSTABLE LOCATION LOT #3 e%jj " W `�- . SEWAGE # VILLAGE OSTERVILLE , ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ELLIS BROTHERS CONST. CO 362-6237 SEPTIC TANK CAPACITY ,le,6c, LEACHING FACILITY:(type) G ocS (size) NO. OF BEDROOMS - PRIVATE WELL OR PUBLIC WATER .oi CiC BUILDER OR OWNER ,,r ZA a/; DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: a - VARIANCE GRANTED: Yes No 9 J X6 1 as ....................... ItII-FT. EST MINIMUM'20 SOIL_�'T q t4 1)CLEAN A By D MINIMUM. .WITNESSED DATE OF SOIL Mn &PERCOLATION 'RATE CONCRETE,,-COVERS VA' TION- HOLE 1 OBSERVATION HOLE 2 0�PVC PIPE 2 LAYER,'OF SER 1/8 TO ELEV.N. PITCH 1/8 PER FT. 112" ELEV.--�'CONCRETE - ASHED STONE 0 COVERS' TOP' AND 12 MAX., isu",CAST:'*ON PIPE., BSOIL R,' IEQUAL)IFT I/4*"�PER bw"�LINE 0 TMIN ELEV. 0 oo ::ELE 0 yy.ELEV. (>IELEV. w t ' EL WATER AT- EL=- WATE R t0 0,0'ELEV. o 0 tI N ,DISTRIBUT 0 D ESI GN CALCU LA TI ON S 314w TO /2 017 DROOMS ,w 0 NUMBER ,-BOX WASHED STONE: 0 00: ETO 'o GARBAGE DISPOSAL"UNIT,TED BE :WATER 0 ,IF-MORE THAN ,'ONE OUTLE "T 000 GALLON T" OTAL� ESTlMATED FLOW. GAL/8R Y _ BR-) GAL/DAY./DA I 'A SE P T1 C,TANK - REQU'DIA. IRED"SEPTIC' TANK,CAPACITY GAL PRECAST "LEACHING AL TUAL SIZE-OF ,SEPIC"AC TANK OCJ G I F TS ACH AREA REQ(�ZONE OR EQUIV.13ASIN ING JIBf MEN tDEX IN > GAL/S. .�AR'EA DEWALL,Sl� BOTTOM AREA ADJUST I 11 0 , GAL./S.F*SEWAGE ' DISPOSAL SYSTEM ' �PROFILE A NOT,TO SCALE', CHING,CAP, -(BOTTOM -SIDEWALL) GAL/DAY 'cv,4r Zy f4t,tRESERVE:, LEACHING CAPACITY GAL/DAY 'TEST HOLL,--OR USGS PROBABLE :,,WATER TABLE ELEV.B&-ftOM -OF. ELEV,,z=OB SERVED WAltR 'TABLE:l: 'E.P.-�ALL-, KMANSHIP :AND �MATtRIALS:'SHALL CONFORM TO D...... TOAND�'THE:i WN 01`�,, LES AND' LEGEN "-nTLE,--,5 1., WOR - U R L `THE�,'SUBSURFACE,DISPOSAL OF SEWAGE..REGUlLA!WNS,',FOW. 2- i-covE T6`tANiTARY' EXISTING !SPOT,ELEVTION RS , BE BROUGHT TO tTiNG ,ICON76UR-,--��.;-�66�-OT., �O 0 116N .'GRADES"SHALL'REMAIN. ESSENTIALLY THE''SAME.FINAL,sP ELIVA -FINAL 3-:E)(IS*nNG AND FINAL-'tONTO ' OMPONENTS -OF THE 'S BLE OF-Ok SOIL TEST,- LO -BE CAPA ANITARY ' TEM 'SHALL: 1 �'LOAPIN -Tt4E-Y-.ARE_-UNDER ,OR WITHIN THSANDWG'Hm� O' G 'UNLESS T POLE DR VES 0 -PARKING AREAS- ,�H 20 LOADING,SHALL BE UTILITY, R OR, WITHIN 1 0 10'TOWN--,WATER.: W 'USED 'UNDER FT.':OF, DRIES :,OR.PARKING 'AREAS.0 GRADE 'SHALL,'."TO'BRING' COVERS CATCH' BASIN 5 ANY.-MASONAIRY iUNITS; bSED"7 BE�'MORTARED�]N PLACE." -MADE.:AS,10 COMPLIANCE,�WITH-6 ' NO:'DETERMINATION,,HAS BEEN. lo�'DEEDED 'OR ZONING ONS. OWNER.FROM ;'APPROPRIATE AUTHORITY.APPLICANT IS REGULATI BTAIN,,SUCH DETERMINATION..7 ""A 0 A- Alij-IF If JP - ""APPROVED- "BOARD, �'OF' HEALTH' lz Iwo too AGENT. DA P-f V PROPOSED PLOTTLAN q F R IPROJECT LO 7 CATION'STANLEY-�,,R-,-SWEETSEA ' INC.7 oe v 97 �SEA STREET MASS. 02639 I398-3922 � DATE I7 SCALE /z, REVISED REVISED R J B NO MA 0 LOCATION SHE ET�l OF