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HomeMy WebLinkAbout0085 PEACH TREE ROAD - Health 85 Peach Tree Road Marstons Mills Commonwealth of Massachusetts @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments - 85 Peach Tree Road Property Address Peter Goode Owner Owner's Name information is MA 02648 Jul 29 2013 required for Marstons Mills _ Y_..__ every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may ;ot be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not --__ - - ------._-_-----._.._. use the return Name of Inspector key. Septic Inspection Services Co. -- - -... Company Name se PO Box 1487 Company Address Marstons Mills MA 02648 e City/Town State Zip Code -- -- 508.428,1779 Sl 12855 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 Uj- C:) r July 29, 2013 JO # 13 70C (�sp,ctor's Si ature Dale w co The system inspector shall submit a copy of this inspection report to the Approving Authority (BcWM of Health or DEP) within 30 days of completing this inspection. If the system Is shared system loD has a design flow of 10,000 gpd or greater, the inspector and the system owner, shall subNlt they report to the appropriate regional office of the DEP. The original should be senito the system o"er 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. t51ns•3113 Offnai nspect'cvi r nnn Sunsunace Sewage Dsposai System•Page 1 of 17 �L Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments e a 85 Peach Tree Road _ ...__.._ _. ...... _._.._ Property Address Peter Goode _ Owner Owner's Name information is Marstons Mills MA 02648 Jul 29, 2013 required for -- -- - - ..._ ..... .. _ ._ - -- - - -----------------._... every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was not in need of pumping at time of inspection. leaching chambers had 2-Y of standing water at time of inspection. 8) 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 fain -e 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): 15ins•3113 rule 5 Ofi caai tnspe.choo Forrn Subsurface Sewage Disposa�Sysiem-Page 2 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form I=� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 85 Peach Tree Road Property Address _Peter Goode Owner Owner's Name information is Marstons_Mills MA 02648 _July29_2013 required for _ _ .-_.. . --- -- -- ----------- every page. City/Town 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 ❑ N.D (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ N) (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordE.ice with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 I iue 5 Official nspeclion Dorm SubSurtace.Sewage Disposal System•Page 3 of 17 l u�^ Commonwealth ofMassachusetts . ��^��8�� �� �������*^��� N������������^���� ����N~N�� Title �� ���� � ������� Inspection W-��nwwn Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments � 85 Peach Tree Road Property Address Peter Goode _ _ _ _ ---------------------____-___'--___-_- mwne, Owner's Name information is N1em0ono �WiUo MA O2G48 July 2O13 required for __-__-____- - '- ------- every page. c»pfT»wn state Zip Code oa.H of Inspection B. Certification (cont.) 2. System will fail uni000 the Board of Health (and Public Water Supp|ier, if any) determines that the system ia functioning inu manner that protects the public health, safety and environment: Fl The system has a septic tank and soil absorption system (SAS) and the SAS is within 10O feet ofa surface water supply or tributary \oe surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 ofa public water � oupp|y. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. F� 'The system has a septic tank and SAS and the SAS \a less than 1OOfp,�t but SU feet or more from a private water supply weU°° Method used to determine distance: This oyaham passes if the well water analysis, performed at a DEP certified |abonatory, 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 ������� CU System Failure Criteria Applicable to All Systems: You must indicate "Yeo" or "No" to each of the following for all inspections: Yes No | Backup of sewage into facility or system component due to overloaded o/ clogged SAS o/ cesspool F� DioohargeorpondmgofefUuen\ \othnou�auenfthegnoundorsu�acewahem �� �� due to an overloaded | dSAS or cesspool Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Peach Tree Road e e od Property Address Peter Goode Owner Owner's Name information is Marstons Mills MA 02648 Ju: 29, 2013 required for JL,!y 29, --------------- every 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 CM 15.303, theret,)re 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 II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 I nL 5 Official insperbnn romp Subsurface Sewage Disposal System•Page 5 0l 17 L | Commonwealth of Massachusetts . ��~��N�� 0� ��^��~�*^��� B������������^���� ����N°N�� N ����� �� ��y� � N������ Inspection �-��wwwn Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments � 85 Peach Tree Road � Property Address Peter Goode Owner Owner's Name information is K8a�hzno ��iUo [@A 02648 July29 2013 required for ------ - - ' ------- - -- every page. C»pT«w» state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" an to each of the following: Yes No Pumping information was provided by the mwna', occupant, or Board cdHealth | El [K Were any of the system components pumped out in the previous two weeks? � 21 El Has the system received normal hmms in the previous ^vnweok period? � �� �� Have large volumes of water been introduced h» the oy�emrnoenUyoraopa� of �� �� this inspection? �� �� VVereas built plans of the system obtained and examined? (If they waenot ��� �� available note aoN/4) � Was the facility or dwelling mopoo\ed for signs of sewage back up? � Z Was the site inspected for signs of break out? [K D Were all system components, excluding the SAS, located nnsite? Z El 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? �l VVasthe facility owner (and occupants �d�e^enthom mwne� pnov�edwhh �� �� 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: Z n Existing information, For example, a plan at the Board ofHealth. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [31OCIVIR 15.302(5)] � D. «�x������ UU����K����'��U� ~~. ,~�..~~ Information .. Residential Flow Conditions: | 4 3 ' Number ofbedrooms (deeign)� - Number ofbedrooms (actual). ---------- DESIGN flow based on31OCIVIR 152O3 (for examp|e� 110gpdx # ofbed 44On�omn)� ----------- / | 15ins-»n3 m*5oxic° inspection Form sbsunac°Sewage Disposal System'Page s*o � | Commonwealth of Massachusetts _ = Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 85 Peach Tree Road Property Address Peter Goode Owner -------- --_.._._.. Owner's Name information is required for Marstons Mills MA 02648 July 29, 2013--------..---- --...._..-._ .._ ... _ ._ . ._.. - _.._.._.. - - -----...-------------- - every page. City(Town State Zip Code Dat-of Inspection D. System Information Description: Number of current residents: 2-------- - Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)) -------------- Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/industrial Flow Conditions: Type of Establishment: _ _. ___-_. Design flow (based on 310 CMR 15.203): ----Gallons per. .--..p-e-r-_--._. ._..---------_--.---.____...__-----_.--- day;gpd) Basis of design flow (seats/persons/sq.ft., etc.): _._--------____._—__.____ Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - - -- .... -- -- --- --- - ----- 151ns-3/13 rile.5 Official Inspection Form Subsurface Sewage D'sposai System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form /l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 ' 85 Peach Tree Road - Property Address Peter Goode Owner Owner's Name information is Marstons Mills MA 02648 July 29, 2013 required for Slate Zip Code Date of Inspection ---...------------------- every page. City/Town _ D. System Information (cont.) Last date of occupancy/use: date Other(describe below): General Information Pumping Records: Tank pumped April 2013 Source of information: - Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped aeons 9 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): l5ins•3113 TOIe 5 ofhaai inspection Form Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 85 Peach_Tree_Road _ Property Address Peter Goode Owner Owner's Name information is required for Marstons Mills MA 02648 July 29, 2013 _._...------- - -- - --- - -- —-- every 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: Installed 8/28/02 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): -- -------------- ---- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 14 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: 10.5' long x 5.8'wide - 1500 gal. Sludge depth: 2 t5ins•3113 1 me S Official inspecoon Form Subsur...:e Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 85 Peach Tree Road Property Address Peter Goode Owner Owner's Name information is required for Marstons Mills MA 02648 July 29, 2013 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 3 1.0 Scum thickness ....- - ----= -- ------- Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13" Measured 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.): Liquid level was found at bottom of outlet invert and tees were intact and clear. Grease Trap (locate on site plan) Depth below grade: reei..---- -- ------- - ---- --- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scumthickness _-- ----____-------._--_----..--------___._-- 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_.-_.. -- --- -- _.....--------- ---- ----- 15ins•3113 1 itle,5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 85 Peach Tree Road Property Address Peter Goode Owner -------------- ---- Owner's Name _.-_-----_.—__-- information is MA Marstons Mills required for _02648_.... ..._..... -July 29, 2013-- every 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 DesignFlow: -__.. ._.._.___.-------.. ---.--.__-----_—__-- gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: __ . __ _.__.-...._----------_--- --------_—_-- Date I Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•3/13 1 Ne 5 Official inspection roan Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0 85 Peach Tree Road Peter Goode Owner Owner's Name information is required for arstons Mills -MA 0264 8.....1-1- July 29, 2013 every page. City/Town S tate Zip C ode 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 ------ 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.): No solids or high stains present. Liquid level was at bottom of outlet pipes. ...... ...... .................------------------- .......... ------------- ................-------- Pump Chamber(locate on site plan): Pumps in working order: El Yes El No* Alarms in working order: 0 Yes El No* Comments (note condition of pump chamber, condition Of Pumps and appurtenances, etc.): .............. ------------ —------ If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required)� If SAS not located, explain why� ................................ ------------------------------ ---------------------------------- t5ins-3/13 Title 5 Ofhoal Inspeclion Form Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 85 Peach Tree Road Property Address Peter Goode Owner Owner's Name information is every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) E-1 leaching pits number: leaching chambers number: Three 500 gal. D leaching galleries number leaching trenches number. length F� leaching fields number. dimensions: D overflow cesspool number: � F� innnvahve/altemadveaystem � � Type/name uftechnology: ------ - --------- Comments (note condition of soil, signs of hydraulic failure. level ofponding. damp soi|, condition of vegetation, etc.): Chambers had 2'3^ of standing water d a stain |i �;' abovouuxent |avei ________ Cesspools (cesspool must be pumped as part of inspection) (locate on site plan). Number and configuration —'--'— Depth —topof|iquidtoin|etinved --'------'------------- Depth of solids layer Depth of scum layer Dimensionsofcesspool -- | Materials ofconstruction ------'--- � Indication of groundwater inflow El Yes FI No � � sm 'ao /file o Official m�° ion Form Subsurface Sewage Disposal System'Page ow/r / � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments a 85 Peach Tree Road Property Address Owner Peter Goode ------------ -------............... .____--- ----..------ - — _.__------- -------- -- Owner's Name information is Marstons Mills MA 02648 Jul 29, 2013 requiredfor ------------------------__ ._.._ __._.._.._... __-----...__- ._._. -----y--------- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: -------_----- ----------___.__._.--_-._-.___._---- _-- -____-- Dimensions Depth of solids --—-- -- — -—--------------- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51ns•3/13 1die 5 Official Inspection Form Subsurface Sewage Disposat System•Page 14 of 17 ¢' Commonwealth of M assachusetts Title 5 Official Inspection Form _ If.; Subsurface Sewage Disposal System Form - Nol for 'Joluntary Assessrr..�nts 85 Peach Tree Road Property Address Peter Gooce Owner owner's Name information is required for Marstons Mills e MA 02648 July 29. 2013 ever y page Cdyi7own 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 belt.v ® hanc-sketch in the area below ❑ drawing attached separately arae 8 0 27 20 36 29 41 Peach Tree Road Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments /. 85 Peach Tree Road Property Address Peter Goode Owner Owner's Name information is Marstons Mills MA 02648 Jul 29, 2013 required for -J._ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20 Estimated depth to high ground water: feet-- ------- - ---- Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: - - -- --- ---- -- -- — - Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water more than 20 feet lower than property elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•3113 1 dle 6 Official inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0 85 Peach Tree Road Property Address Peter Goode Owner Owner's Name information is Marstons Mills MA 02648 July 29, 2013 required for —-------------------- every page. CityrTown 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 Z System Information — Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 1 Ne 5 Official inspection Form SUbsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARnNSTABLE LOCATION �6� I\ 4TrZe- VILLAGE SESSOR'S MAP.&PARCEL V49T?Mt*W S NAME&PHONE NO. e �V 1t L lm SEPTIC TANK CAPACITY 1 ,506 LEACHING FACILITY:(type) 7:�, C"2 , (size) NO.OF BEDR OMS OWNER PERMIT DATE: 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 ori` site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY \ t \ \ \ Y \ Y \ \ \ \ t \ t \ Y \ \ Y \ 4 t Y t \ t Y \ \ Y \ t Y J f f f F•,. ! f r l F F f F Fv? !.f f r f / ! F ! f f•r r fvr t \ Y k t Y•\ trY Y -Y+k k t't .+tr Y+'v Y v kt Y \ \ Y k \ \ t \ \ Y v. t \ \ Y \ trYr Y Yr♦ \ \+Yr ♦ \ tr v. 'v \ 4 Y Y 4 rY 'v ! ! ! r f f'F vJ f ! f Jv Fv fv! v.+v/ •vl vF of r r�J �! ��f�f r r t \ k Y t \ v k Y vr♦ 1 \ 4 t v Y t Y ♦ Y v • \.\ \ \r trt rt t Y Y rY Y \ Y t Y t Y t t \ \ \ t t \ Yr Y v v ♦ Y \ ,. - ! Y Y \ Y \ t Y Y Y k ♦ t t t Y v, t Y k \ Y 1 f f f 1 F ! F J r ! F r F r f J f J f Y t Y \ Y Y Y Y \ \ ♦ \ 'v Y \ Y ♦ \ t \ Y . 0 27 20n 36 29 41 Town of Barnstable P# Ig1b, -2 Department of Regulatory Services Public.Health Division Date 0`fHE f- rq, . gyp` q� 200 Main Street,Hyannis MA 02601NARNSTABIA NABs. t> Date Scheduled 3 U oZ Time- I '(4,41w Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By 5 '��� ►-�� _ Witnessed By: '►�A tZal,s:6�Ts1,1� 0 0'► E � 1, owner's Name Location Address rs-pe A . tM j r'S , Address M. Q �/%�l✓� STEPHEN J. AOYLE & AS OC. Assessor's Map/Parcel: 5 7 f U� Engineer's��l�iame d 42 Canterbury Lane 0# !" East Falmouth, MA 02536 f Telephone NEW CONSTRUCTION REPAIR ;# 4 Land Use Slopes(0/0) nes i Distances from: Open Water Body ► ° ft Possible Wet Area ►s O ft Drinking Water Well 1�ft Drainage Way ft Property Line \o ft Other ft SKETCH:(Street name,dimensions of lok exact locations of test holes&perc tests,locate wetlands in proximity to holes) Ail Cr v P �0`5 Parent material(geologic) _TP Depth to Bedrock_ Depth to Groundwater: Standing Water in Hole: N.t buA V— Weeping from Pit Face Estimated Seasonal High Groundwater QL,'-Lot tA V ►0 Saw"� " �Hm m Pw Method Used: 'V—A A Vr7 Depth Observed standing in obs.hole: in. Depth to soil mottles: in, Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level i r;is i i t P.A� ,:�� I�I r....., ii. �I,�� i11pi � �ppy. i I d.i�• I•I,A 11. �;�i 1� ICI I'it'p; '.1 '`'�"i �:�, Observation ( Z Time at 9" Hole# Depth of Pere '39 I►' Time at 6" Start Pre-soak Tune® ►0 J 0 1 d`.1 Time(9%6") End Pre-soak ZAp��UI�S>�b�`t`�►�1 ��t��tE To S,��uYaNC'I�r, i Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y![J) .......�:•.v..,!a:i^Y;}}�i}:•:}N; •. p•S i. �:}S}:({•;$•.y:;+'.•rr. , ...Y:Mn. a:•,:v:;i•i:C:?:}?:i:2.�}:•ti•7.>.v:•: }�;,•(/. �`r�rj.•.:,K•/�ny }:j�, •'• ^.TC,'...... v:,:•r'J7.:• •.:��:.�•.w:.�:{::.�: 'T _•"i.Y•rT� ...n ..... ,...,;. �L<`.'�+:;•,•:}v.•.r:.�:�:::a•77xi,••7a{:y•{:::..bxas.... k•:}x:�:4{2•,.:a:>:::+ ofl•Cofor •. $Oil ' Depth from Soil Horizon Soil Texture $ Mottling (Structure,Stones,eoulderes. (USDA) (Mansell) ;,0 • Surface(in.) , sty \o-1n BIZ t�rend it ;;'74 VW M. L;k AN 061 :>.•:.:;•:::.::;;<};;:.}.}}},,•::.;}. Soil er ??•);•:•:>.££:ti£yti•`Y7>i;.'Y•7.}::.:}iC•..;;r:;'�.;:::;•iYi�.�;..}'::Y,.•.}:.}:'4}:^}:aa}\:{{}+.};9,.:.hy,::v,::A{,�.:...:..:•.: . Depth from Soil Hotlzon Soil Texture, Soil Color Mottling (Structure,$tones,Boulderes. Surface o, (USDA) (Munsell) ° 0 cAM ::{•}:•}:Lh}.�::;;•;Jn•:+::. .:•4. vNH;. � t`r"I'i �•�7 .. T!Tl<4;.•• ••X••'}•:r'•:t:'••:':'':S{::i:}}:•:•.•.'•}. ...j,}•,,•}.�- , ..:.,i... :....,..,•.;:tf:��,i'„•�'..,..�,r��+'"' .,:} .,>•}:3 .;;.= ,�:2 :. ..t..:•.:`•}:d4:>s}: ..OtherY y'{a.::.ry::.};�:::�>::s{:::;.: ....•..:.}:....... :. �'� $Oil Depth from Soil Horizon Soil Texture Soii Color Mottling (Structure,Stones,Boulderes. Surface(in.) (USDA) (Munsell) ° :s.,.,•:: .,,}},: ::;:::^:« ,.:7a:,¢i; ct:;4K Other }.;•'2��s':' '.•'•. :i::o•••.••:�'\ Soil•1-Iorizon. .. Soil •Depth from Soi(Texture Soil Color'•}4{� (USDA) (Munsell) Mouling (Structure,Stones,Boulderes. Surface(in.) ° Grayell ----------------- Mood Insurance Rate Man:. Above 500 year flood boundary No— Yes Within Soo year boundary No— Yes Within 100 year flood boundary No,_, Yes pen h of h'aturallY Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all dreas observed throughout the area proposed for the soil absorption system? If not,what-is the depth of naturally occurring pervious material? Sertitication -� I certify that on 0`y (date)I have passed the soil evaluator ex ination approved by the of .11mrR nnaNsk was performed by me consistent with TOWN OF BARNSTABLE LOCATION 'irT SEWAGE # �3 VILLAGE- 67/ - ASSESSOR'S MAP & LOT J`�-7 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Sdc1 G/9C LEACHING FACILrrY: (type) Jae/„/akmLj C3�_(size) /3 NO.OF BEDROOMS Z (BjII DEIOR OWNER G/U PERMPTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet f leaching facility) Feet Furnished by C�e *4y-v G. �r _r. A` 00 ebb N)f ' 06 7-C)q r A -r No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: e PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Y application for Miopozar *pztem Construction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Nam Address and Tel.No. AY Assessor's Map/Parcel �7,10"S �11LC: Installer's Addre and Tel.No. m Designer's Name, rl arlLerbUxy Lane . � -0L OTr] East Falmouth, RA 02536 a Telephone: 508/540-2534 Type of Building: wel ' g No.of Bedrooms 44 Lot Size sq. ft Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow AA® gallons per,day. Calculated daily flow_ .6t 54, gallons. Plan Date JA"1 0 c Number of sheets k Revision Date Title Svr� v— '1, %A ut -i-&R.. SJ �7� ILc�t� 6 Size of Septic Tank i�,� a Grp tc�k ,�rt ��t-' Type of S.A.S. Description of Soil a 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 Certifi- cate of Compliance has been issued bVth* o d of e th Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued19 a t .;�v�-*• �, � � � .. 1 ems. .r'"K. - Fee THE COMMONWEALTH OF MASSACHUSETTA'S Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OFBARNSTABLE., MASSACHUSETTS � P 0[ppYication for Migonl bpgtem Construction j3ermit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. $5 �— r"�t Owner's Name Address anndd Tel.No. Assessor's Map/Parcel �2y� A, f Installer's Address,and Tel.No. © Designer's Name, d e.NNo.DOYLE & ASSOC. Canterbury ,Lane 0rZO East Falmouth, MA 02536 Telephone: 5'08/540-2534 Type of Building: well•.,g No.of Bedrooms `Lot Size . Garbage Grinder( ) Other Type of Building No..of,Persons Showers( ) Cafeteria( ) Other Fixtures !'c.X Design Flow Leo gallons per day. Calculated daily flow 4 gallons. "'---Plan-Date 'Mk\`J1�_ 0 q , ?_o 0Z_ Number of sheets k Revision Date Title S r vs-_ L 4U4-,, '--®tLN 8S- -3r.Ae..0 Size of Septic Tank 1 5'1<3 vt-A k�tr�t- �T' Type of S.A.S. cJ�Am S7- l-nam4J3 0 Description of Soil 5aen5-_ L.6q4 t r t 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 Certifi- cate of Compliance has been issued by th' "Bo d of H 3 th Signed a -- D to - n ApplicationApprovedby Application Disapproved for the following reasons a Permit No. 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( )b /D 6 / "of 5 7— at has beto constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ated Installer Designer The issuance of this permit shall n t be construed as a guarantee that the syste will function designed. Date ��� Inspector t_.-Q- c .�--�C,`�) ,(w ),•2_.J. �'�\ — —t ---------------------- Fee No. '� //9 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS wigool *p.5tem Construction Permit Permission is hereby granted to Construct( Repair( )UpgraV1, Abandon( ) System located at &�. �e e 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:Constructiof!(�ust e com pd within three years of the date of this mint . Date: / //\ � Approved b �.. PP Y �/ TOWN OF BARNSTABLE LOCATION g� ��n �J SEWAGE #AMP Y3 VILLAGE ASSESSOR'S MAP &LOT 1 INSTALLER'S NAME&PHONE NO. 49,21alW,' ? SEPTIC TANK CAPACITY /S-aa GEC LEACHING FACILITY: (type)J�G-1 l�a��-� C3� (size) /Y >•33 E 2' NO. OF BEDROOMS y BIM R OWNER G� 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) Feet Edge o Wetland and Leaching Facility(If any wetlands exist wid in 300 feet g facility) Feet Furnist ed by V R yA ` O O 'bb q) r� .. Ili'+neytir r r, + c r � � r l 77 U7 (; - - pr.elivrirtary_ plslt!s,and layouts by OC D are for rile-yse of thtir Customers only.Any othe, use is st„ct,y P,oh,bite _ s ,q d t ' t _ i ..1:..J F 9 w—, aunt-W - - �J.• 1 ..l'�P.�LJ ZO' .b�[_ c� 1Z:o" ci .. i ' 3 TZI T. Y 77 7777, 43 s b.tJ'". 'L ftSF` ;. S:O' 1 a0 1'.0' ,f.S'.8.. i '.. i 9• I �c_ �witsr.rr �. r s -15 77.7 14 n. a 4 t,... -�* -xL.• «=.-7, lv' ti+. "!`r s.,-�-e s�. - �• s.: y = f R f . v ' �r 1 s �4�^ - � .T:��y. -'r.. '4 s�'.� '��'—" .'1'.� 'b`�`" '•r'_ -er 4' .�-�: c ` pg � 4'j'?,4:; use of ttwi, C.suo 1f3 oOI.a[�.. .D2hC�'Yw;6vftlfY� w". + ... .. {, - PreluJsinary ,plafirSnA.f s.by;$C ice do us .Y, ^Y .: .. - .. ,p: p . � `�+•�mcmil6l"if::iv�: O:vs.�1. v :� -. ".': .d- .1$m+� •,••n�F6 .S..v _o.w .}... -. - — , ' I2•'Q�'•G�'�;AED- 'i'76i.$':y�"'A{�5b1?; I o9i.mi�Ai - -a-r.:e'. i : t � : ' . ' fCONG.!7LEU;dU.Y COL 'DO•no.N v LL4 _ J' 6'OIA�LONG et ID iUEFB -DN EaF.^. 1<� A1serm (F.¢j�stS CF i f F • • i ..ram_—__. ".. .- . .... c{•::p '.j4G 3 ' t� t t, f } y h e � 3 ' ,...,�". ,q, - .,, ""Pr 41f m1fT!>y plan"1.and'1•syqu[c Dy-QC:�1l prl,I;pr IFic oit of'tFie{r Cu3[CmCrII only'.nAy;oThe[we iS.[riC tly 'iD?li cif r , T ,� 1\7 7 It--- 34" I-AAy. Lc v t� a+l cz s l s t' C•6M1P�N Cz-1``�r ---� TOP FOUND. ELL 0 2" of 1 18" - lj2" Peastone CID o�o It WAnM p o o rWT caves 1NV. EL. 1 tell Trench "dth �iencl: Length 3 ,5 ' FLOW LINE r � r 3!-�" - 1-1�,2" •$ '. INV. EL. - � 1_�1;;� Trashed Crushed Stone I Washed Crushed Stone TY h 14 tsl•4'S �13 PROF 0 ED . c.. r � �J IRE'11TC1-I SECTl0.111 1 V MN. C UCuld C�rtla 0 . • , / •�O , - INV. EL e, _ c= L. Trenches , NV E GI.-Le INV. EL. 41.o 8 -.' No. of renche No. of 500 Gallon Precast Chambers _ 1500 GALLON, PRECAST REINFORCED CONCRETE SEPTIC TANK PRECAST REINFORCED CONCRETE 3/�t" - 1-1/2" Washed Crushed Stone-- " DISTRIBUTION BOX MINIMUM CONSTRUCTION MATERIALS PER 31OCMR 15.226(2) 0 TEES,SHALL'BE CONSTRUCTED OF SCHEDULE 40 PVC AND INSTALL ON A LEVEL BASE SHALL EEXTENO A;MINIMUM OF a ABOVE THE FLOW UWE MINIMUM WALL THICKNESS 2" �A�� �� OF THE,SeP-nC TANK AND BE ON THE CE147MUNIE OF THE SEPTIC TANK LOCATED DIRECTLY UNDER THE CLEAN-OUT MINIMUM INSIDE DIMENSION 12" MANHOt.E OUTLET INVERTS SHALL BE EQUAL TO EACH THE INIV PIPE ELEVATION SHALL BE NO LESS THAN 2 NOR DESIGN DATA: x. OTHER AND AT 2 MINIMUM BELOW INLET INVERT. MORE THAN`3" ABOVE THE INVERT ELEVATION OF' THE Yw } OUTLE`f PIPE. Res06 THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX STRUCTURE �.� ► SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING TYPE N0. BEDROOMS GARBAGE DISPOSAL ��` �H SEPTIC:TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION ON A LEVEL .St/►BlE BASE`THAT HAS BEEN MECHANICALLY LINE INVERT AFTER ALL LINES HAVE BEEN SEALED IN PLACE. _ DESIGN FLOW �x�w f aP� COMPACTED AND ON TO WHICH"SIX INCHES OF BRUSHED STONE INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE � HAS BEEN PLACED TO ENSURE STABILITY AND TO PREVENT AND NON-DEFORMABLE MATERIAL PERMANENTLY FASTEND TO THE 0 '^ LINE OR RECONSTRUCTING THE LINES UNTIL ALL INVERTS ARE OF , 'SETTLING. EQUAL ELEVATION. SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9". i SEPTIC TANK - 7H00-20' MANHOLES WITH READILY REMOVABLE IMPERMEABLE COVERS, OF DURABLE MATERIAL SHALL BE PROVIDED W1TN ACCESS P01tT3 BANG PLACED AT THE CENTER AND OVER THE INLET AND -. - LEACHING FACEJTY 3�'��-;-3 x,•Z.� . OUT,,.ET TEES: \ 12 THE OUTLET TEE SHALL BE EOUIPPED WITH GAS BAFFLE. > GRAPHIC SCALD Cenral Consh' iou Notes _ ; i IN FM 1: rq All the .01k lanship and materials shall conform to D.E.P. Title 5 and the Town of - - - 6 ` , _ ti Barn able rules and regulations for the subsurface disposal of sewage. 64 - - - - - - - - - _ _ inch 20 fL e4 z37•59 ` 2. At least one access port over tank tees shall be a ible within 6 inches of finish grade, I wlih any remaining access ports brought to within 12 inches of finish grade: 1 ' ` $, + i ._ ZOMNG DLS7RIC7ti RF y ez N82'10'00 E ' X ASSMSORS DATA: 3. All components of the sanitary system shall be capable of withstanding H 10 loading BUILDING SETBACKS:• MAP 57 PARCEL 94 . t W ; ,, unless they are under or within 10 feet ofdrives or parking. H 20 loading shall be used _ FRONT-30 under or within 10 feet of drives or parking unless noted. ed pri��p--_ -' � '+ SIDE & REAR-15 FEMA DATA.• ZONE "C" \ I Pr°� OVERLAY DISTRICY.1 4. The eac�Ivat / har�dr shall verify the location of all site utilities prior to any ` �t.- AP & RES/PROTECTION 5. Sewer pipes shall be 44nch Schedule 40 PVC laid at 0,02 slope. 135.9' S, W Proposed ;. 6. Any masotuy units used tO bring covers to grade shall be mortared in place. , ��'� W` S. A.S• Trench �. , Finish shall have a minitnum.s of 0.02 feet foot: grade tope per O k i Proposed - &� � p -- o ,` fi 'A Of Wg ` q? 70 Proposed 1500 gallon IP , o �"' , - 7 oil Log3 �h M I DweMng Tank 'LP+a 1NaLIAM 1 V s ` `, '+ ; ' `' L AN Test Do te: May 3, 2002 , �,�, o �, + n. hen 1?0 le `� 1 sit LOT 26 Sidi 'E'vrlua tor: Step .p ss cr o f b 'A j rr2 t 4i 33,268�sq.ft. ` � - �S'ite Plan of -La 1 \ -Bit. Hyri/Pln le ' 1n Inch i \ 44 z-$� ---�'- , El 64,90' Prepared For. Pere Re to / ` ' Datum: NG VD 27.5' 85 PEACH TREE' ROAD 1 W t B2 �\ � Eris In tal.t. 4.�c,s �e.t.. �3•�► 0� 0" `,\` ,W ` 64 Ut31/Pads Barnstable, Massa ch use t is "A" SL 10yr Sf2 "A" SL 10yr 3/2 „ 6 ` �W �I 86 s ��sedcontour Ca tch Scale: 1" = 20' Da te.• May y 09, �200�2 Basins $" LS 10yr 5/4 n "B» LS 10yr 5/4 ,�� - - T_ - - - - �W 303.34 �� DenoteSeE Co Prepared By.• a - - W ri H 28 ------28 , Stephen J. Doyle And Associates I 42 CanterburyLeese, .� Felmoutl� MA 02538 4J ��• t' W 1 , , Telephone. 50B/540-284 C C .dlED. � ` ee LIED. " t I Re v3Sio ram. •B1oc3-� # . v w SAND 2.5Y S/''4 .Pew 39 SA1VD 2.5Y 6/4 ` s8 p•55'4 ` eo60 e,2 84 . k ' 120 a a:, r d eer En untered No Ground Water Encoruitered 'o Grr�un x 7A ., BY NO DATE DESCRIPTION , a , .:. - -. r ,......,.. t..x ...E ., :. ..-. ... ,,;. ":. .. ,. ,. .. .. ..2.;..... - r, r , r d' y