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HomeMy WebLinkAbout0100 PEACH TREE ROAD - Health (2) 20 Rigging Way - Marstons Mils i; ; A= 057 j 078 J I i i I No. 4210 1/3 YEL elM1 4 V 1000 0 O0 OIL,) © 4 - v�a- Commonwealth of Massachusetts �v Title 5 Official Inspection Form r.t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... 20 Rigging Way 01 v Property Address Lauren Jordy Owner Owner's Name , information is Marstons Mills ✓ Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection _ Inspection results must be submitted on this form. Inspection forms may not be altered,.in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information cc on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 cd Company Address Sandwich Ma 02563 City/Town State Zip Code r. (508)477-0653 S113747 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 o9^aN'sgreaq&en nb�ai Brett Hickey DN: Hldd 11�• a.a�w®���,�.m�..�.•s 8-28-2018 Inspector'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 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth�, of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑■ I have no.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 was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced cr 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �e ,IF Title 5 Official Inspection Form �a1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way �u Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewac�e Disposal System Form Not for Voluntary Assessments ..� P Y rY 20 Rigging Way Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 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 '/day flow ❑ El Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ E] Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Se--tion 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way �u Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E] Were any of the system components pumped out in the previous two weeks? ❑ El Has the system received normal flows in the previous two week period? ❑ Q 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) ElFx Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? 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? ❑ a 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 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 I c Commonwealth of Massachusetts �m ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 20 Rigging Way v Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms(actual): 348/gpd DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes E] No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes CE No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: ***2016-106,000gallons 2017-98,000gallons*** Sump pump? El Yes ❑0 No Last date of occupancy: June 2018Date t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 20 Rigging Way u— Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- pumped 1 month ago 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 c Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; 20 Rigging Way L Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.), 4: Type of System: E 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: New SAS added to existing leaching in 2016 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): . 11811 Depth below grade: feet Material of construction: ❑ cast iron ❑Q 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town waterfeet Comments on condition of joints, venting, evidence of leakage, etc. ( 1 9 9 :) t5insp.doc•rev.7/26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 18, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way L— Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 811 Depth below grade: feet Material of construction: W 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 1 Dimensions: 000gallons Sludge depth: empty 11 11 Distance from top of sludge to bottom of outlet tee or baffle rr r� Scum thickness n n Distance from top of scum to top of outlet tee or baffle n n Distance from bottom of scum to bottom of outlet tee or baffle 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.): The tank was pumped after the residents had moved out and has not been filled again. Tank is empty but was viewed and appears to be in good structural condition. t5ins.doc-rev.726/2018 Title 5 Official Inspection Form:P p Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �d ,/p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top P of scum to to 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - g P Y rY 20 Rigging Way V Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every 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): 0'r 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �- ,lp Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 20 Rigging Way u Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every 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.): NA " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2) 500gallon FX1 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way Property Address Lauren Jordy Owner Owners Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in working order at the time of inspection and was dry with no high staining. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): l5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way v Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts �d Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging Way Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every 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-sketcl- in the area below ❑ drawing attached separately Driveway Al-1W B1.15' A2.23' B2-20' A3-48' B3.27' A B LT Abandoned t5insp.doc-rev.7/26/2018 Title 5 Official Inspection 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 20 Rigging Way V Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑E Check Slope ❑1 Surface water ❑■ Check cellar ❑E Shallow wells Estimated depth to high ground water: NoGW@132"feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 2-22-16 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: A plan on file.with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts j �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Rigging.Way Property Address Lauren Jordy Owner Owner's Name information is Marstons Mills Ma 02648 8-28-2018 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. �■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ■� C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Chteria)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 -b I TOWN OF BARNSTABLE LOCATION ,20 ki . W-lv SEWAGE# r , yy VILLAGE � `8� � ASSESSOR'S MAP ,&PARCEL INSTALLER'S NAME&PHONE NO % SEPTIC TANK CAPACITY LEACHING FACILITY- (type) Jer) r'p, (size) NO. OF BEDROOMS OWNER PERMIT DATE: :jl,- —,(', COMPLIANCE DATE: Separation Distance Between the: t'��f'. `'r4 iti rL 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 of leaching facility) Feet FURNISHED BY jA v 0 D W Opal'-t.of 1.71 L.t— / .z _q'7 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes t PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 1 ZippYiration for Disposal opstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. DO _j,SyteuS (N� Owner's Name,Address,and Tel.No. Y AsM��M}11S _ 0��.. w�e�� Installer``'s J�- Name,Address,and^Tjell.No. Designer's Name,Address,and Tel.No. A Rc�� N S �v ➢N N / Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building tee,%s�sil4` No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) {7 j!)n gpd Design flow provided `.'(f S,:7 gpd Plan Date 2-2 2— I Co Number of sheets 2 Revision Date Title \ Size of Septic Tank 1C[��,^�P Type of S.A.S. 2S rwC���®vJ ono 0(Ana nn os 4 t$b N r. Description of Soil Nature of Repairs y.orAlterations(Answer whenapplicable) �Ns \\ Gi N e_(_0 0 tidy. C � d4 // 5(OC7 A a\(0 3 C`JlC�M1tl0'r ..� �}� �{( S�N 1P A) C, \',.e V;Y, - r /"C re" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. e © Date " Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION - TOWN OF-BARNSTABLE, MASSACHUSETTS r21pplication for Mis oral stem Construction i3rrmit Application for a Permit to Construct( ) Repair(0� Upgr ade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Trot No. V, &5St Nf wc„y � Owner's Name,Address,and Tel.No. !' Assessor's qMap/Parcel MJS ��J�. / W e,Installer's Name,Address,and,Tel.No. Designer's Name,Address,and Tel.No. Type of Building: t Dwelling No.ofBedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `�?�� g d Design flow provided 7-5t4 J8,:"T gpd Plan Date Z - 2 2 G Number of sheets Z Revision Date Title Size of Septic Tank G )g-!!S Type of S.A.S. 2 ( C c"-,)VN:J� r\n A6(S q�St0 f1)r Description of Soil Nature of Repairs or Alterations(Answer when applicable) q 1V n_0 [� V)ox CA(� - Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. V0� e Date �"' 3 1/ Application Approved by L p /� bate /' Application Disapproved by Date for the following reasons Permit No. Date Issued 62 --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance t THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) P Abandoned( )by "�o0 G c A S-�k at ( N < N i c re..,( AA u�ir,r1S M �S has been constructed in accordance with the provisions T�and thetfor Disposal System Construction Permit No. ��t/VVdated Installer'Dn OCG S A 12,D Qnw iJ T NC Designer N cj,y m f, Lit)(k S #bedrooms ^?,� Approved design flow 3 gpd The issuance of this permit shall not be construed as a guarantee that the system will function degigned. Date '?�/ (� Inspector �{ ('/ ;,q /e , --------------------------------- - -------------------------------------------------------------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem nstruction Vermit 'r Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at O c Lt A.Ac, �cc s Al � Ct f 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. a Provided:Construction must be comp ted with' hree years of the date of this permit. i Date Approved by / 1 v i 1 k � (1 Town of Barnstable Togo Regulatory Services Richard V. Scali,Interim Director anxrisrnai.�. +" gc� p�0� Public Health]Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: ZC Zg<< Sewage Permit# a D[62-011 Assessor's Map\Parcel O57—GZ'Z McEnFe.e PE- Designer: ,; a ,�„ r,y �, IL , Installer: 0, A , f3rb,_u.4 C_ Address: 1 z, LAY. Address: P 0 � 1-2v X 1 LI S f:r-Ms l-okku_ tJ Z 6 Lf y On A-, ra.,.i� 1�►�, was issued a permit to install a (date) (installer) septic at sep y _� �'y 5 - t .based on a design drawn by (address) t-c t"1 C�Ve.& P V, dated Z Z 1 C (designer) KI certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow_ Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co fiance with the terms of the I\A approval letters(if applicable) o PETER T. sIaller i�gna�,e a McENTEE N CIVIL No. 35109 RfGISZER`� F� (Designer's Signature) (Affix Design Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DliTISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH TMS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BAR.NSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q_1Septic\Designer Certification Form Rev 8-14-13.doc j Town of Barnstable P# oFt�r o� Department of Regulatory Services i + BARNSTABLE,1+ Public Health Division Date MASS. v� 1639. � 200 Main Street,Hyannis MA 02601 ArFO MAt a 1r Date Scheduled-. d ,Timed Fee Pd. t 0_0 Soil Suitability Assessment for Sew ge isposal Performed By: IZ- H ,S essed By: (/'✓' �� LOCATION & GENERAL INFORMATION Location Address Z e) pZ Owner's Name i0 iV_6 _ro_ Address � .5;t11 ei W CjWA f„ Assessor's Map/Parcel: ,( C-7 (� 7i 2— Engineer's Name NEW CONSTRUCTION REPAIR Telephone# ,5 Q6'7j, 2 Land Use 12Q, ' � h Slopes(%) Y Surface Stones 'v Q I ' Distances from: Open Water Body /wvJ,4— ft Possible Wet Area /von ft Drinking Water Well St Drainage Way Aj jo!j— ft Property Line T�---ft Other ft 4. SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) ILI I I 1 2 11\ 2 Q �o 3 j2t4C�-tNC>r �Psy i Parent material(geologic) VV)-W-t1 k Depth to Bedrock j ,1 Depth to Groundwater: Standing Water in Hole: /vb rJ- Weeping from Pit Face Estimated Seasonal High Groundwater 3� tt DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment _f). Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time _ Observation Hole# � PAL Time at 9" IDepth of Pere 4)It)- Time at 6" _ iStart Pre-soak Time @ G Z t A Time(9"-6") _ End Pre-soak 5��d Sa`� s eh ev d G Rate Min./Inch i Site Suitability Assessment: Site Passed_�� Site Failed: Additional Testing Needed(Y/N) i Original: Public Health Division Observation Hole Data To Be Completed on Back----------- f ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC I Lv DEEP.OBSERVATION HOLE LOG Bole#_1 Depth from Soil Horizon Soil Texture .Sdil Color Soil Other P Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones;Boulders. itoo v A LS (0yr144 4.4 2 1. S ld ,2s16 C DEEP OBSERVATION HOLE LOG Hole#?- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselt) Mottling (Structure,.Stones,Boulders. Cons'itency.%Graven_ -`� l.s toy�ylz- i _2!0 L 5 to (2S/6 Z,ra -13� C -C Sties DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. ns tency.%Gravel) i , A DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. o si;9mcv,%Ornvell_ I i ! I I Flood Insurance Rate Map: / 1 Above 500 year flood boundary No_ Yes I . ` Within 500 year boundary No.� Yes I Within 100 year flood boundary No Yes „ Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervi s material exist in all areas observed throughout the area proposed for the soil absorption system? ( �, If not,what is the depth of naturally occurring pervious material? _... I Certification e certify that on �� (date)I have passed the soil evaluator examination approved by th I c fy . Department of Environmental Protection and that the above analysis was performed by me consistent with the required tr ' expertise and experience described in 310 CNfR 15.017. f i Date Z 1 � • Signature I i .x Q:\,SEpnC\PBRC11ORM.DOC i p (Y'4-3S: LlTC V N S EW.A C E PERMIT NO. - VILLACE j s INSTALLER'S NAME i ADDRESS BUILDER OR OWN[. DATE P-E It Oil T .ISSUED DATE COM ►,LIANCE ISSUED '7_� .� : iL _ 1 } _ V by • ..y �J �/ V i -V ' l a � ��-�1 � � Fl No'.............. �s...7. ................. 0'�( " THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ®u � .................oF........ p ® : ............................ Ir Appliration for Miposaal Works Tonstrurtion rerun# Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at .................----•- _.... ..i �..--W--•-- ........... !!!..1�1.....Location. --•-•-•--•-•-----......---•--------....�..�-----�2----------------------------- pN dress , or Lot No. .................•. _ ... I�i-4.O.D. 0........ ..........----------------...------.........--- --•------.......--------------------•-...-----• W _._.r Address ............---------------- ---- ..................................... Installer Address Type of it ng Size Lot..........44?3 .., fee Dw - g—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grind Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafete is ( fl, Other fixtures -------------------------------------------- W Design Flow.....................Si9L._ .......___,gallons per person per day. Total daily flow...................33. ...........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..........I_______-_ Diameter............... Depth below inlet.............. Total leaching area...® .---sq. ft. Z Other Distribution box (14 Dosing tank ( ) &.I�, .J�Date pPercolation Test Results Performed by .. .1 .is-----__--- ...._. - -� ......... ,.� Test Pit No. 1........... minutes per inch Depth of Test Pit.................... Depth to ground water.........._............. Test Pit No. 2................minutes per inch Depth of Test Pit_-____------____-__ Depth to ground water........................ R+' ---------------------------------------------•-•-----------•---..........................----_-----•........................................................ 0 Description of Soil---------------------------- .................... ..............................•-------••••----------------------------•--•••----•-••---••------------ ------------------------------------------------- � . �k ....------------------------------------------------------------------------------------ W ------------------ ------------------------•-----------------------------------•--------•------------•--••---------------------••------------------------------------•-•-••--•----------.......... V Nature of Repairs or Alterations-Answer when applicable................................................................................................ ---------•-------------------------------------------------•-------------------------•-•-------•--...-----....--------------.........-------•----------------------......---------------••----••-••----. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee •ssued by the board of health. Ifollowing gne -----------•-----•-- ......---- Application Approved By.... ----------•-......•-••----•-•-----------...---•------------- Date Application Disapproved or reasons--------------------------------------------------------------•----------------------------------------..._...._ Date PermitNo......................................................... Issued-....................................................... Date Fxs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................OF..........`i..: .`>.f =h ,t 6 Appliratiun for Diupuuttl Workii Tomitrnrtiun ramit Application is hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal System at ? ... ---•-_.....•---- ............................................... Location-Address _ or Lot No. .................... l L C.tom_ i..�.Cam.i.� s-: ........ ............................ .._............ •.----.....................................-- &ner Address a ...................... �F' ............................................... ------....------------•--•--...-•-...------ •---------............---- Installer Address i� 7 Type of B g Size Lot...... fee U Dwe1 ' No. of Bedrooms............. _.......... .__..Ex Expansion Attic a g— ------.-- p ( ) Garbage Grinder` aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafete Otherfixtures -----•------------------•-------------------------••--.-------•-------------------•-•----------------------•-••----...--• -------------- W Design Flow...................... ..t:......_...gallons per person per day. Total daily flow..................... c?..........gallons. WSeptic Tank—Liquid capacity.l.G- gallons Length................ Width................ Diameter---------------- Depth____-__---_---_- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. � Seepage Pit No...........I..... .... Diameter.............0_ Depth below inlet........lr,,i?...... Total leaching area...10-?--...sq. ft. Z Other Distribution box ( V� Dosing tank ( ) � Percolation Test Results Performed by..6' ,. ,.. ._..� ...................i_...........Date....... ........ Test Pit No. 1..........2-minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -------------------------•---------•----•••---•-••----•--------.....---------.............-----....•.............. .................... 0 Description of Soil....................................................... ...... •---•------------------------------•--------------------•---------------------------...------------- V ._-, W M. -------------------------------------------------------------------------------------------------••-----------------------------------------------------------------------------...................... U Nature of Repairs or Alterations—Answer when applicable............................:................................................................... -•--------------------------•----------------------------------------------•--------•-••----•.--------------•-•---------------•-------•-----•---------------------•-•--•-------•--------------•----••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the board of health. r . igned=-----------------••-•-------------------------------------------.-------------- ------------/-----------••- ate Application Approved By._,�..... . .'' r!�_- .......... Date Application Disapproved r t following reasons:---•--------•---•---------------•----------------•-----•--------------- -----------•------------------=---••---- ..............•--------------•---•---.....--•-------•--•-•-----------........---------•--...------.....----------------••-------....--- -----------------------------------------------•--------•------- Date PermitNo...................................--------------------- Issued-........................ ........... Date 4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .:..............OF......... E1iLo .'z. .! ........................ ` (9rrtifir t,e tt of (hunt linnrr IS� �CE!?ZIEY;That the Individual Sewage Disposal System constructed ( 4or Repairedgas- ( ) `. .. 1-, ...._ ----------------- ---------•----...........----•----------------•-•------------••---•---•----••--•--------------- , i r� Installer - at ' '' 2-2 .�t ..:.: �a t: �ias een mstled in accordance i h the provisio s of TITLE 5 of The State Sanitary Coen c��sc ed in the pplication for Disposal Wo k"s o str `~ 'on Per it No.__ .::. '. dated.--.._ :._ _. _' S __-___-•_____-_- THE ISSUANCE OF ISfCE TI SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE SYSTEM WILD. F CTION SATISFACTORY. DATE....../.. . r�: .................................................. Inspector........ ••. ..................................................._........_........ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH •1 - No..:.t(. . FEE...... :............ Diuvuunl or r tonotrttrtiun amit Permission is h eb ra = r Y g ••-----------------------------------•--•---•---•----------------•--------.....------.........._..........-- to Construct -y r�R,epait t,/)man Wdivlduall Sewage Disposal System atNo... Y ---• .......±' . .. .• .r" .---•----------••------•-S -------------------- -------•----•------------- Street r as shown on the application rr, sal Wor s C nstruction Permit No..-.-.,- ..... Dated. ___ _._ ........................... . ....................................f Board of eAlth DATE........................ .............................. FORM 1255 HOBBS & WARREN. R N. INC.. PUBLISHERS j g1it Gl L- FAWL- - aEoczoonn s�4c -r LOT- 'L ►,J•O' GAR�gAGE GANDER. '�' �.0w .. IIo x 3 a3oG.Pv '. SEPT►C TANK = 33Ox15C>% y5E ►000 GAL. 1 o15Po5AL PIT v5E to co GAL. :. , .II, Y, •,1.�..��� I 150 50TTOM AQF-A- ' q2 "ToTA l- <7 ESIGN a A.z S G.P D. -ToTA%- >A I L.�( FLOW = 330 C•RO wi COLAT1otJ RATE = I''�N VAIN OV-Lt~55 iA OF* RICHARD � ALrAN A. We 'e y to JOKES" 1 24048 r 0 5100Q` .r. .i su T6��T L -� -�� ��• lot Y/V/ TOP FN9r.l@ ..? Iwo 100 QIWQ�P 1-G,4NA ►oov WV. -• a j E , c., D1ST. Q ' 7f/ L BVX INV. 56PTIG INS GA4.. , . LEAGu �B INV. PITINV. a82 q�•� wrrw a1a WASUGD �I GEt--rI r- GD PLoT PL.AtJ PRUFILG L044."TIo1.J (� No . SCALE { s_ ��� �d�••� 5.12-g3 '�b �` - nT'• P�--A N REF 62EN GE GEwr%sr- 'THAT THE {-soVSL� Sr0WN I KEREtoW GOMPL`(5 WITN-CHE SIDI�L1N �.vT �2 A u D 5 t=-T 5AC K R.6 Q V I R.>c M N'f� qq F -C VIE" -To W N O F T3 ARt.1�iTi43t,�,A�v 1 S 'f" LOCt.TE0 •WtTN► T t} FLOOD PL IN CL� ?Owe /�-l�''�1 C.• DAT E Gl rZ INC.-Y ti 6 BAXTEiZ II.A1.1 D's u 7-Y EYo1�S 71.l13 PL&KI I�5-p NcrT gASF'p old AN 03TE2VILLE • MAss- `'IuSTRuMENT 5u2veY No-T DI~ 'u5E.DTo 0r- I eFCP�11►�rc LoT t-INES aPP1..ICA►J'f P L �I VO�ekI� i LTG °k'g 1 o• •Y . PaoP• 4 � v II' low•a i r .•� 1 V to A �• ,a 3 �„ tit,�' • Cp J i q1,.s pvim+7- SAD a."^- Ice Loo - �,t1 �, 1• 11% OF M� • E�CHARO G o� ALAN .�yG A. W. e BAXTER, �, . JONES Na 24048 0. 100 Q� T R j. Saar l 4c, t. Town of Barnstable Barnstable .�. ; Regulatory Services Department A �STAXM I 1i6 9. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL 9 7015 1520 0000 1971 7057 November 25, 2015 Brian P. Whele&Lawrence J. Toye Whelan-Toye Family Trust 9 Squaw Creek Drive Haverhill,MA 01830 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 20 Rigging Way,Marstons Mills,MA was inspected on July 31,2015,by John P. Graci, Sr, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet(per Town Code 360-9.1). You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH • ean,R.S., CHO Agent of the Board of Health e7 Q:\SEPTIC\Letters Septic Inspection Failures or Future Ev1\20 Rigging Way MM Nov 2015.doc i 'VFW T Town of Barnstable + 3ARN3rAHLE, "A ibjq, a Regulatory Services Department p ,�� Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,•2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year.not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool ❑Any portion of the SAS; cesspool, or privy, below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA. ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code 3 60-9.1 OTHER Repair deadline: WSEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc 11/03/2015 13:21 5084573658 FH ADMISSIONS PAGE 03103 fi I; CGMMOUWOO ftth of Iassachtrsetts IOL6,ciaj inspection Form Sabeurface s4wage Disposal System Form-Idol for ! rY ' 20 RIGGING WAY ___,_- ____...__.._.__�,.._.,,__._—._•._.r_- --__._.---� ATETHE =STr HQMAS M W owner p;"F ine )7131t2_0_MA - , -- - ---- 5 ijeffnatton is mARSTOC�S YILL� .- — State Zip Gods )ate of roquimd fof every Qtyaown page. • inf oTmation (cont.) Type. -— m---.. � number: Teaching pits IeaChin$chambers I! number. ------- -... _ Q i! leaching galleries -- leaching trench®s Number, ler nth. . leaching fields number,dir tensions: - O numbeir. - i. overflow cesspool innoVativeJalternative•system TypeJname of technology: soil;cvrrdi±:gin of comments(note condition of soil,signs of hydraulic.#allure, level of p►nding,damp vegetation,etc-)i �;9X 1Wti,HES 1000 GALLON LVCH 1�1T SHOWS SiGmES OF BEING FULL.Uot 1ID LEVEL IS(S}- __.. _.. TO THE Its F_RT PIPE-,._.. .— Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration NA Depth tap of.liquid to inlet invert NA^_•�„r_.,r_.__..._..__—._... pep ',of.solid tayer EeptS o1 scum layer NA• - Dime lions of cesspool w _� matehals of construction Q Yes ;� Put► Indication of groundwater inflow O�ctlOt�for+:S+ r<� Odspo:tid Sys+ Pago 93 Of 17 Twe 50 t5ina•M 3 i I• j' dWr 1 5VI-11 vpj, cl 0 VVV Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY = Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name �µa information is Uri required for every MARSTONS MILLS MA 02536 07/31/2015 page. City/Town State Zip Code Date of Inspection �X) XP 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 filling out forms A. General Information on the computer, ✓1 /���0 use only the tab 1. Inspector: key to move your cursor-do not ,JOHN P GRACI SR use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS LLC r� Company Name PO BOX 2119 Company Address TEATICKET MA 02649 City/Town State Zip Code 508-641-6694 S1468 Telephone Number License Number B. Certification 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 Eval ion by the Local Approving Authority 40&- 07/31/2015 Inspector's Signature Date The system inspectors II submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)withi 0 days of completing this inspection. If the system is a shared system or has a design flow of 10, 00 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Dispo alai y�ge 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information i every required for every MARSTONS MILLS MA 02536 07/31/2015 page. Cityfrown 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: NA 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): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 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): NA ❑ 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): NA C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (an Public Water Supplier, if an y) 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: NA ** 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: NA 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 II clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 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 II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 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 c�M 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK DISTRIBUTION BOX AND (1) 1000 GALLON LEACH PIT. Number of current residents: ZERO 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 d TOWN 9 ( Y 9 �9P ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UNKNOWN Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NAGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 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: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 11611 Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: GREATER THAN 10+ FEET feet Comments (on condition of joints, venting, evidence of leakage, etc.): AT THE TIME OF INSPECTION THE SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY. DISTRIBUTION BOX APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY. LEACH PIT SHOWS SIGNS OF BEING FULL. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AT TIME OF INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS. If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: STANDARD 1000 GALLON Sludge depth: (10)TEN INCHES t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. CitylTown 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 (24) TWENTY FOUR INCHES Scum thickness (6) SIX INCHES Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES Distance from bottom of scum to bottom of outlet tee or baffle ZERO How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON SEPTIC TANK . RECOMMEND PUMPING EVERY TWO YEARS. SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. Grease Trap (locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 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.): NA Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. City/Town 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 BOTTOM OF PIPE 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.): 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.): NA * 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: NA t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every . MARSTONS MILLS MA 02536 07/31/2015 page. City/Town 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.): 1000 GALLON LEACH PIT SHOWS SIGNS OF BEING FULL. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA _ Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 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.): NA Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. CitylTown 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 t �• N M G► FRONT AHB '51- 15 �a• 21 �- ?� t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10'+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) e ❑ 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: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 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 20 RIGGING WAY Property Address THE ESTATE OF THOMAS M WHELAN Owner Owner's Name information is required for every MARSTONS MILLS MA 02536 07/31/2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file s t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 'I LEGEND N BENCHMARK - EXISTING CONTOUR OUTSIDE COR./SOTT. STEP x 16.82 EXISTING SPOT GRADE 28 �• EL.=103.88 0 -W 0 EXISTING WATER SERVICE o,)�e LOCUS co 100.47 -G EXISTING GAS SERVICE R oo`c� q�P a -U UNDERGROUND WIRES eTv x 102.88 TEST PIT P% N 79'45'112 W >� I BENCHMARK �a oed9B 101,82 205.I56' N o a z JW 100.99 of l. . ~{ m n. CL 9 102,39 Q� X LOCUS MAP LOT 92 TP-1 TP-2 Lbw .o O ...,.f i a NOT TO SCALE 26,630 ±SF ^o O MBL 057-022 101.17 102, " ' o x 103.7 / /`OQQ 04.9 G 104.79 100,55 101.12 03.68 f, ' �/ JG 104.86Cb GENERAL NOTES: 0 103.30 r ��^� 101.02 x 103.88 ! 1 17 1 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL N PLL _SJ /i BOARD OF HEALTH AND THE DESIGN ENGINEER. 1J0 102.7 PECK 103.71 + oo / 107.93 \\ 2• ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS '�``' OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE p 99,E R x 105.53 a L I i LOCAL RULES AND REGULATIONS. EXISTING 1 `1�y 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 10,148 �1oo.a7 x x TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE HOUSE(#20) I `�„f i DESIGN ENGINEER. 1fl 1 103.16x T.O.F.=106.Of x 105.05 �\ x 106.47 0) & 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING M J` EXISTING LEACH PIT FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN -�g.6_� o� GARAG 105.15 iT /` PUMP, FILLED WITH ENGINEER BEFORE CONSTRUCTION CONTINUES. 01.f9 104 3 �'`'� x SAND AND ABANDON 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. 0 18 pC �w> 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 105.49 105.14 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 7. ''1 Q�'.�.104.02 73 ! id3,80 103.38`-;;.- 1 104.43 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. ! ! :.'.:s' 7. WATER SUPPLIED BY TOWN WATER SERVICE. ! 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 103.26,'•s"'P,4VED�-� :s� rL(7�� L�(„ , 104.41 `1• 1 101.50 x (\ .o :'t.::pRIVE.;:' c6 O`Z EXISTING SEPTIC TANK 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 104.79 0 TOP OF TANK, EL.=104.15 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 102.\33 x `c��\ ,� 1:, 103,49 INV.(OUT)=102.8.f(VERIFY) DIRECTED BY THE APPROVING AUTHORITIES. x104.83 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY i ent THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING I '. a` x10 o�em CONSTRUCTION. of P A� 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS x 99Y,9 8; edge �` 1- IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). R. .'.<;'` 101.09 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY A LICENSED.SOIL EVALUATOR PRIOR TO BACKFILL. TC BASIN y 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 100.17 IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. R of Mgss9��G 98.63 \� o PETER T. g MCENTEE PROPOSED SEPTIC SYSTEM UPGRADE PLAN o N 20 RIGGING WAY, MARSTONS MILLS, MA VIL o. 35109 EGIS1 -R`�� Q i Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 SS/ OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO. WHELAN, THOMAS M & MARY T TRS WHELAN-TOYE FAMILY TRUST Engineering Works, Inc. 1"=30' P.T.M. 103-16 9 SQUAW CREEK DRIVE 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. HAVERHILL, MA 01830 (508) 477-5313 2/22/16 P.T.M. 1 of 2 n NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:99.5 SEPTIC TANK FOR A DISTANCE OF 15' AROUND THE 5' INSTALL RISERS & COVERS OVER INLET PERIMETER OF THE S.A.S. PROPOSED S.A.S.; N 1 ROP AND SET TO 6" OF FINISH GRADE. PROPOSED D-BOX yl S .S.1 PROVIDE ACCESS TO GRADE OVER OUTLET COVER INSTALL WATERTIGHT RISER & PROVIDE TWO ACCESS MANHOLES TO WITHIN 3" 1 OF FINISH GRADE FOR INSPECTION PURPOSES T.O.F.=106.Ot COVER SET TO 6" OF GRADE F.G. EL.=105.5t F.G. EL.=102.0(MAX.) hg �11$ F.G. EL.=105.Ot � F.G. EL.=102.2t ��• g1•'� MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L - 42' L = 5, ® S=1% (MIN.) ® S=l% (MIN.) 4"SCH40 PVC 4"SCH40 PVC ' U-i6 DECK as �:i0"1 6' aaa274" aOaa EXISTING ae" uvulo 4' 4.8' 4' EXISTING LEVEL GASADBaD,FFLE INV.=99.80 PROPOSED INV.=99.63 HOUSE(#20) INV.=102.8 D-80 EFFECTIVE WIDTH = 12.8' T.O.F.=106.Of FLt (EXISTING-VERIFY) INV.=99.00 EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS GARAGE SURROUNDED WITH STONE AS SHOWN H-10 RATED TOP CONC. ELEV.=99.8t BREAKOUT ELEV.=99.50 SEPTIC LAYOUT INV. ELEV.=99.00 aaaa NOTES: EEMOM M aBaaa aaaaB aB6a 6a6aa 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE BOTTOM ELEV.=97.00 INVERTS, PRIOR TO INSTALLATION. 4' 2 X 8.5'=17.0' 4' 2 D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE 4' MIN. OF NATURALLY OCCURING ON A MECHANICALLY COMPACTED SIX INCH CRUSHED PERVIOUS MATERIAL EFFECTIVE LENGTH = 25.0' ' MIN. ABOVE GROUNDWATER STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 5 LEACHING SYSTEM SECTION ®®®® ® ® ®® 3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTT. OF TP-1, EL.=90.0 - ®®®®®® ® ®®®® 33" 4 CONTRACTOR SHALL INSPECT EFFLUENT FILTER ON 3/4" TO 1-1/2" DOUBLE Of ui ®®®® ® ® ®®® OUTLET TEE AND REPLACE IF NECESSARY. WASHED STONE N z ®� 3" LAYER OF 1/8" TO 1/2" SEPTIC SYSTEM PROFILE DOUBLE WASHED STONE (OR APPROVED FILTER FABRIC) 102" DESIGN CRITERIA SOIL LOG 4" KNOCKOUT DATE: FEBRUARY 1, 2016 (REF#14,943) 20" DIA. COVER NUMBER OF BEDROOMS: 3 BEDROOMS SOIL EVALUATOR: PETER McENTEE PE(SE#1542) / HEALTH AGENT R.S.SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) WITNESS: DAVID STANTON 4" KNOCKOUT 4 KNOCKOUT 58" DESIGN PERCOLATION RATE: <2 MIN/IN ELEV, TP-1 DEPTH ELEV. TP-2 DEPTH 0 DAILY FLOW: 330 GPD 101.5 ALOAMY SAND 0 101.6 A 0 DESIGN FLOW: 330 GPD LOAMY SAND 4" KNOCKOUT 10YR 4/2 10YR 4/2 2 GARBAGE GRINDER. NO-not allowed with design 101. B 4" 101.3 B 4" LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF LOAMY SAND LOAMY SAND 500 GALLON CAPACITY, H-10 LOADING 10YR 5/6 10YR 5/6 CHAMBERS .74 GPD/SF 99.5 C1 24.. 99.4 26" EXISTING SEPTIC TANK: 1000 GALLON CAPACITY C1 PERC PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED N.T.S. USE 2-500 GALLON LEACHING CHAMBERS IN SERIES M-C SAND M-C SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 10YR 6/6 1OYR 6/6 20 RIGGING WAY, MARSTONS MILLS, MA SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. I Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. ROUNDW Engineering by: SCALE DRAWN JOB. N0. TOTAL AREA:.................................................... ... ..... 471.2 S.F. NO G ATER1 138" Engineering Works, Inc. NTS P.T.M. 103-16 90.0 138" gp, DESIGN FLOW PROVIDED: 0.74 GPD SF 471.2 SF = 348.7 GPD a OBSERVED 12 West Crossfield Road, Forestdole, MA 02644 DATE / ( ) REERENCE PERC: 4/11 78, <2 MIN./INCH. CHECKED SHEET 2 / (508) 477-5313 2/22/16 P.T.M. 2 Of 2