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HomeMy WebLinkAbout0151 PEACH TREE ROAD - Health 151 Peach Tree Rofit ad Marstons Mills A= 056-063 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name -0 information is MARSTONS MILLS MA 02648 6-5-17 ,r; required for -11 every page. City/Town State Zip Code Date of Inspectior�5 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 A. General Information SAf /'aYD r--- forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address (j— CENTERVILLE MA 02632 II L1 Cityrrown State Zip Code 5084204534 S14297 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Qx"4' C-p— 6-5-17 Inspect6fs 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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 'E the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 rof 1177 �� Y J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. City/Town 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 an information which indicates that an of the failure criteria described ® Y Y in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USAGE. TANK WAS PUMPED FOR MAINTENANCE AT TIME OF INSPECTION.THIS REPORT CAN NOT BE USED TO DETERMINE BEDROOM COUNT OR DESIGN FLOW OF THE SEPTIC. 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): F t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M �< 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. Cityrrown 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- 1 0,000g pd. ❑ ® 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. Citylrown 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Forth: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 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. City/Town State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND 4 LEACHING CHAMBERS Number of current residents: 4 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 ears usage d NA 9 ( Y 9 (gP ))� 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 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? tank truck Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , ' 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 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: leaching 2003 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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: 2 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts a r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): Tank was pumped at time of inspection for maintenance. Inlet end of tank was partially under latice work on deck. sono tube appears to be close to tank but does not appear to be on the tank. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins 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 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 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 Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every 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 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box level no leakage or solid carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection 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 M , 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): At time of inspection there was no clear signs of failure in area of s.a.s. S.a.s was not opened due to depth Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer . Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. Citylrown 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.): l t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M � 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 i every page. Cityrrown 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) ❑ 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: previous passing inspection reportdated 4-22-11 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 o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 151 PEACH TREE RD Property Address KRAICS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6-5-17 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 05/19/2011 12 25 FAX 5084290875 Ww Raeeis Real Estate ®078/017 C CommonWealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Peach Tree Road Property Address Martini MscNeeN Q✓AW owaels Rama Wornation I: Marston MillsMqufredforev Ma 02W 4/P9111 page. cW_ state Zip Gode Data of kvpectim D.System Information(cant.) ' I Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or bmehmartks.Locate all wells within 100 feet Locate where public water supply enders the building.Check one of the boxes below. ® hand-sk—s"in the area below 0 drawing attached separately G _ I w A I. V II z 4 B! 141 . f �33 =140'G CZ= ITT " C3`- Lf • I. �-osae Tab Saanm Wsphe Ary SabWrm$0v pUko dar4em-Page IS&17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 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. General Information on the computer, II use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B& B Excavation, Inc. r� Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the ---I information reported below is true, accurate and complete as of the time of the insp&ction. The':inspeetion 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: >, Ic; ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ) I 4/22/11 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. u ( i t5ins•09/08 Title 5 Official Inspection Form:Subsurface S age Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. City/Town 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 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 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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•09108 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 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Peach Tree Road �M Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 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? ❑ E 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection-building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 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: 5.2x5.2x8.6 Sludge depth: no sludge t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape tees present no sign of back up. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4122/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons , Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Peach Tree Road Property Address . Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appeared to be in good shape no sign of carryover or backup. PumpChamber locate on site plan): ( P ) Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): At time of inspection leaching appeared to be in good shape no sign of staing or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form: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 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 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.): t5ins•09/08 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 °M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 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) ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 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 M 151 Peach Tree Road Property Address Martin MacNeely Owner Owner's Name information is required for every Marston Mills Ma 02636 4/22/11 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 FREICENED 7COMMONWEALTH OF MASSACHUSETTSEXECUTIVE;OFFICE OF ENVIRONMENTAL AFFAI15 2002 DEPARTMENT OF ENVIRONMENTAL PROTECTION TOWN OF BARNSTABLE M m HEALTH DEPT. � P Wtl FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM FORM PL. PART A CERTIFICATION ,A Property Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 J�-®� �o Off, Owner's Name: HARTEL �2 Owner's Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 p- Date of Inspection: 9/4/02 0�2s Name of Inspector: (please print) JONN GRACI an p Y Com Name: SEPTIC INSPECTIONSinLtr" Mailing Address: s P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of'the time of the inspection. The inspection was performed based on my training and experience in the proper functiowAnd iri'aintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.3140 of;Title 5(310 CMR 15.000). The system: _ Passes Conditionally ses _ Needs Furth' valuation by the Local Approving Authority X Fails Inspector's Signature: Date: 9/4/02 "P The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec on. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and teopies sent to4he buyer, if applicable,and the approving authority. Notes and Comments I. SYSTEM FAILED TITLE V INSPECTION. SYSTEM IS PONDING. LIQUID LEVEL IN LEACH PIT IS FULL OVER PIPES. ****This report only describ6 conditions at the time of inspection and under the conditions of use at that time.'['his inspection does not address how,the.system will perform in the future under the same or different conditions of use. t �1et1 1. f ' a• • Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 151 PEACH TREE MARSTONS MILLS, MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I _ 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: SYSTEM FAILED TITLE V INSPECTION. SYSTEM IS PONDING. LIQUID LEVEL IN LEACH PIT IS FULL OVER PIPES. B. System Conditionally Passes:' t _ One or more system componants'as"described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the rep lacemelAonrpp4jr,ga approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,�ND) in the for the following statements. If"not determined"please explain. `yea:s'old* or the septic tank(whether metal or not) is structurally unsound,exhibits n/a The septic tank is metal and over''20 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: ND explain: n/a ; n/a 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 _ of s°truction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required um in i t�' a �1i y q pump g more than 4 �mes a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the-B`oard of Health): _broken,pipe.(s)are replaced _obstruction is removed ND explain: n/a t • Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION(continued) Property Address: 151 PEACH,TREE MARSTONS MILLS,MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require,;furtlier evaluatfon 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 Boa 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,50ifeet of a surface water _ Cesspool or privy is within 50 feet of1a'bordering vegetated wetland or a salt marsh t, 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and.soil absorption system(SAS)and the SAS is within 100 feet of a surface water r. supply or tributary to a surface wate'r'.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 an�d1SASiand the SAS is within 50 feet of a private water supply well. { • ftF' x _ The system has a septic'e 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 n/a , "This system passes if the, elI water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. a 3. Other: n/a , � 1 , S•' f Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each"of the following for alLinspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool " X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping morethan 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool o`r.piNy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool<or privy is,within a Zone I of a public well. X Any portion of a cesspool or`privy is°within 50 feet of a private water supply well. X Any portion of a cesspool or,privy is.less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for Foliform,bacteria and volatile organic compounds indicates that the well is free from pollution from that facility.and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.I' I- X _ (Yes/No)The system fails. [;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 cf 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 d to 15 000 d. g YY g � gP � gP You must indicate either"yes"or"no"to each of the following: (The following criteria apply to$la'rge systeitis in addition to the criteria above) yes no X the system is within 400 feet of.a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public watePsu' ' 1 well' 'c.W.% If you have answered"yes'No any.question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system h s kiiled.`fhe owner or operator of ally large systdn1 considered it signif edilt 1111 under Section E or failed under S.ection,D shall upgrade the system in accordance with 310 CM It 15.304. The system owner should contact the appropriate regional office of the Department. 4.}. .f r c, d Page 5 of I 1 ,0 OFFICIAL INSPECTIGN FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 Check if the following have been done; You,must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided,by the owner,occupant,or Board of Health X Were any of the system,components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period'? _ X Have large volumes of water;been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? f ,. X _ Was the site inspected for signs of break out'? X _ Were all system components,exc!,ading the SAS, located on site'? X _ Were the septic tank'manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? ' The size and location oftihe,Soil,Absorption System (SAS)on the site has been determined based on: Yes no ' X _ Existing information. For example, a'plan at the Board of Health. I X _ Determined in the field(if any of,iie failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)],,. k 1.l t f•i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 151 PEACH TREE MARSTONS MILLS, MA 02648 Owner: HARTEL r. Date of Inspection: 9/4/02 iFLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15:203 (f6r example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or;no): NO '. Seasonal use: (yes or no): NO q� Water meter readings, if available last 2 ears usage d Hhr E �V8 i YIV 0 g ( Y g (gp ))�• t7Z � 1 Sump pump(yes or no): NO (� _ —t `� r) Last date of occupancy: n/a Da COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15:203;): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):.NO '. Industrial waste holding tank present,(yes or no): NO Non-sanitary waste discharged to tlie Title 5 system(yes or no): NO Water meter readings, if available.`n/a:` Last date of occupancy/use: n/a a OTHER(describe): n/a ` GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons.,-,How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution bok,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(ifrygs,attach previous inspection records, if any) _Innovative/Alternative technology.-Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy,of,,(he DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1980 BY OWNER Were sewage odors detected whemarriving at the site(yes or no): NO f Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 PEACH TREE MARSTONS MILLS, MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 � s BUILDING SEWER(locate on site plan) Depth below grade:22" , Materials of construction:_cast iron._40 PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete -metal fiberglass_polyethylene other(explain)n!a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' T,'y 4"10':" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top.of outlet tee or baffle: 0" Distance from bottom of scum to ottom of outlet tee or baffle: 0" 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.): SYSTEM FAILED,LIQUID LEVEL IS OVER TEE IN SEPTIC TANK.SYSTEM NEEDS TO BE UPGRADED. GREASE TRAP: _(locate on site plan) Depth below grade: n/a ` Material of construction:_concrete `metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a ,s +K� p, �, ,.�; 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 Owner: HARTEL i Date of Inspection: 9/4/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete`_metal-fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day g Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a y 4 3 DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OVER 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.): � 4 A n/a PUMP CHAMBER:_(locate on site plain) Pumps in working order(yes or no): NO . Alarms in working order(yes or no):NO Comments(note condition of pump,chamb.er,condition of pumps and appurtenances,etc.): n/a 1 } f e, Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 SOIL ABSORPTION SYSTEM(SAS):'X {locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' Teaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a a, '; inbovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs'of`hydrautic failure, level of ponding,damp soil,condition of vegetation,etc.): LIQUID LEVEL IN LEACH PIT IS OVER PIPES.SYSTEM NEEDS TO BE UPGRADED. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:-n%a la' Depth—top of liquid to inlet invert:'n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or,no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a �t PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a >" Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a s f page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 SKETCH OF SEWAGE DISPOSAi L'SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. PYOrC,T a XU t 4 32 6.�r�e i- 1 {it i 1 ', C in Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACKSEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 PEACH TREE MARSTONS MILLS,MA 02648 Owner: HARTEL Date of Inspection: 9/4/02 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 10 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavafors, installers-(attach documentation) NO Accessed USGS database-ex.piain: n/a r You must describe how you established fhe high ground water elevation: HAND AUGER- 10 FT. A i AsBuilt Page 1 of 1 TOWN OF BARNSTABLE 7 L LOCATION _K/ f�=. � 7-r�=,� _ SEWAGE # o - 032 VILLAGE ASSESSO R'S SMAP & LOT G �� INSTALLER'S NAME&PHONE NO. 5'20- S o SEPTIC TANK CAPACITY /SOO LEACHING FACILITY: (type) `�-SDO G�a�Urr� c(/(��stsize) _-,p(, •,X 16, s, NO.OF BEDROOMS BUILDER OR OWNER_11Z Iq v PERMIT DATE: / /-43 COMPLIANCE DATE: ` 03 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fel Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Fey Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fac' 'ty) Fe( Furnished by t.ram i J1 aim' -- I Q N X :J J r .$ c 7ilv http://issg12/intranet/propdata/prebuiIt.aspx?mappar=056063&seq=1 4/19/2011 TOWN OF BARNSTABLE LOCATION SEWAGE # 2o03 VILLAGE Rlt,-5la iS 1�rl,115 ASSESSOR'S MAP & LOT S016 INSTALLER'S NAME&PHONE NO. Y20- Z_ tE ( 5 r, �-c s4liADS SEPTIC TANK CAPACITY /So0 // / LEACHING FACILITY: (type) 'cl ( A%l i/ry W4 57size) X 16-5- NO. OF BEDROOMS y BUILDER OR OWNER k#1,9yr/ /019 �'ll9rT�l PERMIT DATE: l " °,� l-O 3 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 of leachi g faci 'ty) Feet Furnished by �c 4r1/z r,.. ;, 4 - ����� - �9 r . , � . °���„ a\ � , • ,� , I� � ` .7�' I� / `in�� �p`JO�'� b �R� 1r �l- No. } ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,L MASSACHUSETTS 01ppricatfon for Wood *pgtem Construction Permit Application for a Permit to Construct( 41 epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. lv 4 �„ � Owner's Name,Address and Tel.No. Assessor's Map/Parcel ya / /* J I / Installer's Name,Address,and Tel.No. s®�f q yZO ��.3 Design is Name,Address d L/Noo / /`y Type of Building: Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1��5%64�/ — &2 65wc, !!�&y 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 this Board of H alth. Signed Date Application Approved by ` `lam Date I /aJh Application Disapproved for the following reasons Permit No. ZOO 3,y 3 1 Date Issued WIE Fee __e Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Miopogar dip.5tem Construction Permit Application for a Permit to Construct pp• Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. r�l P���G Owner's Name,Address and Tel.No. Assessor's Map/Parcel �' Installer's Name,Address,and Tel.No. 41Z62_ 9?7 f 8 Designer's Name Address d el.No. �I L�hrli'ViG/, Type of Building: r Dwelling No.of Bedrooms l Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when applicable) Zo9S 4411 6,4 �i�s4s2�he ,-­ Geis 72 Li' ��to t�l/_ �4li©c/!�ic, 17 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 this B and of H alth. op Signed Date Application Approved by' �t ,:,> .2 Date 2/�� ... Application Disapproved for the following reasons Permit No. :2 V 0 3 U 3 7 Date Issued I --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate. of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Upgraded( ) Abandoned( )by oS-e,44 1-2i, at / =!� G/� /a/ /S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Np.-2 u a 3-U 3� dated Installer s�/5e,;6:: l4 /l-G `Yi -,o W 5 Designer g: lN�4" The issuance of this permit shall not be construed as a guarantee that the sy t m w},l fun cti a designed. Date 1 1 2 31 D� Inspector X CS . --------------------------------------- No. P OU 3 -0 Fee Z`7) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mtgozai *p6tem Congtruction Permit Permission is hereby granted to Construct( 4)R pair( 1)Upgrade( ) ndpn( ) System located at �/ �/:14G� `f/ �1'lial/.STOhS l�'7i��� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. 1 Date: I j/I d Z Approved by � I Y 5/25/01 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, S ,hereby certify that the engineered plan signed by me dated l 1 ,concerning the property located at / /meets all of the following criteria: • This failed system is connected to a residential dwelling.only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct. preliminary tests at.the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater.table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 4/0"o B) G.W.Elevation +adjustment for high G.W. DIFFERENCE BETWEEN A and B Z 3 SIGNED : DATE: �, 1®3 NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:perceamp 1 i �-� �.�� � �� � _____ 1,nrp� - � �° + ' , ...�- s y 'Town of Barnstable P# Department of Regulatory Services of Public Health Division Date / /,o3 o• 200 Main Street,Hyannis MA 02601 • BAMSTABIA ' � Date Scheduled 0 / Time D Fee Pd. FD MA't� Soil Suitability Assessment for Sewage Disposal Performed By: � Witnessed By: ,/� J- Location Address ',f 1 Pe A, -e••� a Owner's Name A r�p e r t e M4a-JTo/t1.5 R111 s /'r 1 Address /51Ci/ae /� /IC'C'•e Assessor's Map/Parcel: / ' MY Y 140.46 Engineer's Name A//IV S/6'/ �90 NEW CONSTRUCTION REPAIR JC= Telephone# f,0$ 3 9 Y 14123 Land Use 1 I •o Slopes(%) 3 Surface Stones Distances from: Open Water Body y�ft Possible Wet Area ," ft Drinking Water Well ��ft �# Drainage Way .5y � ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) (?trc I i4 Calowip ,� e U Parent material(geologic) ✓ .•*/'� Depth to Bedrock I',�/� Depth to Groundwater: Standing Water in Hole: N Weeping from Pit Face A4nre_ Estimated Seasonal High Groundwater :::-..:::...:...:. r.:.. .:::... TV WWI FxH Me Depth Observed standing m o s. m. Depth to soil mottles: in. Depth to weeping from side dwater Adjustment ft. Index Well# ea mg Date: Index Well level Adj.factor �. titer Level— ' 1�H�e, '�:• IItr4 Observation Time " Hole# /'f •�+"' Depth of Per r I Time at 6" Start Pre-soak Time @ �� G / Time(9"-V) End Pre-soak Rate MinAnch G Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YN) Original: Public Health Division O, �• Observation Hole Data To Be Completed on Back----------- f' Q:HEALTH/WP/PERCFORM Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. ° 1 0 18>1 60 /o YR 31, J✓ 3 Z —jig U ]q �lP OB EIt�ATI01N HO��LOG..<;.;:;.:>. Ho e Depth from Soil Horizon Soil Texture_ Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure Stones,Boulderes. ° Gravel) o . ........ :::D P.: .:�SER". ::::::::H(,........:.....................:. ::::::::::.:::::::::::::::::::: : ::::::.:::.:..: 4 :::::::: :::.::::. .::. . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure Stones,Boulderes. t JJ .>... E .. .. . . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (SWc nes,Boulderes. —Consistency.° tyravell Flood Insurance Rate Mangy Above 500 year flood boundary No— Yes Within 500 year boundary No— Yes Within 100 year flood boundary No_ Yes Depth of Ngturally Occurring Pervious Material Does at least four feet of naturally occurring pervio is material exist in all areas observed throughout the area proposed for the soil absorption system? Te S If not,what is the depth of naturally occurring pervious material? Certification y I certify that on FS (date)I have'passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trttining, peruse an expe • nce described in 310 CMR 15.017. Signature Date f ' TOWN OF BARNSTABLE LOCATION / � P�s4Gyj 7-rCF SEWAGE # -2oo,3 VILLAGE ASSESSOR'S MAP & LOT &/_f INSTALLER'S NAME&PHONE NO. 4/20- J� E ()of c 6 122, 4_ SEPTIC TALK CAPACITY LEACHING FACILITY: (type) .5�-SDO (9�a/�ry W&I size) 6•(P,,X NO.OF BEDROOMS y BUILDER OR OWNER GLIl9//r671_ �'I PERMITDATE: l ^2/-D3 COMPLIANCE DATE:_� _ 23`0_5 Separation Distance Between the: Maximum Adjusted Gfoundwater 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 Wedand and Leaching Facility (If any wetlands exist within 300 feet of leachi g fac• 'ty) Feet Furnished by �c• � / . y I 0 r I ` • ` I L O�CATION SEWAGE PERMIT NO. VILLAGE i INSTALLER'S NAM i ADDRESS c Co • UILDER OR OWNER u r J2�c DATE PERMIT ISSUED oz DATE COFAPLIANCE ISSUED //, 7_oLd .� �d� _ � � �� �I \ 17 . � f� ��q �\ � � �- . �� , No.- =--• •�--`C Flcs. .................... THE COMMONWUL.TPH OF MASSACHUSETTS s BOARD OF HEALTH i ................Town................OF_...Bulrn6t.Lbte.......-.-.-----------•---------•------------.._..------ i Appilration for Disposal Works Tonstrnr#iun rrmit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Peadh jue Rd. Lot# 15 ................__....__...:...........- ....._....-------------------•-----............... .................•-•---..........••----------....•----.........--------------------••--•...-•-••- Location-Address t or Lot No. ....................F,0 2241 ...Re luv n w t.....--•-•.................... •.---------I..TaVrhia--Rd.-••K,i n4j4t-a . ---A4",6..................... Owner CenteAviUe, MaS ss /s ....................&C.11...Ca11&t--CD------•-•-•-•------------•-------------------•- --••----••------------- •-----------------•---------.....---- •.......-----------.... Installer Address 37 192 d Type of Building 3 Size Lot..._....?..................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 010) 04 Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) PL4 Other fixtures ........................................... d ------------------------------------------------------------------------------------------------------ W Design Flow...................$5.....................gallons per person per day. Total daily flow___-_---------_3U..................gallons. W Septic Tank—Liquid capacit3d.,0.Olrallons LengthSS_!_6ti...__. Width.4'_1.Q!l.... Diameter................ Depth..5.!.8!l..... x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No...........1._...... Diameterl'.5 ........... Depth below inlet......6'.......... Total leaching area....240.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by...BaX t A,.,6..Mye-=_..A....1.0 aeA................... Date..81-5/40........................ 1.4 Test Pit No. 1......2........minutes per inch Depth of Test Pit..........1.2.'.... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_-_--_____-__-----____. ----------------------------------------•------..........-•------------..............-•--••-•••••........................................................... O Description of Soil......V...e(7a1r1-• --- 1��2 _0.( ,_.2_-.4..'... �I.�ty.. a�d,---4_!-12' mPd_-dartd,--na._1uaet�________________ x V ....•-•-•-•-•••.....•---••••••••••••••-•--•••-----•...-••••-•-•---•-••-•--•--•-•••••••-•.....••-•-•-•----•••--••-••••--•--•••-•••••••••....--•-•--•-•••-•••--........•-••••......•---•..........--•--••- W 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 TITU ` 5 of the Stat unitary Code—The� lgne er agrees not to place the system in operation until a Certificate of Compliance has been iss e boar h Sied- ... .. . .................... ........................ ................................ Dat Application Approved By--••• ......... ....................... Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------••-_..._ --•-•.....................•------••----------------------------------...--•------•-----------------------•--•-••-•-••-••••-•--•••-•-•••••-••-----••-•--••••-••••••••--••••-----------•••••••-......••--- Permit No......................................................... Issued.1 . . "U''-e ..............................Date............ Date No:. •- ......... Fss.. ......................... THE COMMONWEAL"H OF MASSACHUSETTS BOARD OF -HEALTH ---_-....Town................OF...... ...........................-............................. App iration for Uispoii al Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage.Disposal System at Peach. Tnee,Rd. Lot# 15 .............. -_......_........._...._:. ..... ....................................•..... --•---------.-------------.-....----------------------•------------- ..:.:;...:..::_. ; Location-Address or Lot No. ......................nb. i�d..�Z� Input --.---.----_1 Ta h.,(.2uE--RC r• & .td�4.•-,".5'&----................ �' Owner CenteAv• p e hI_dd ess a .................... C6._A:Q1 .f0.............................................. ....................... ............................ ..•.... ......... Installer Address Type of Building 3 Size Lot....3...19...'........Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (A/J Other—Type of Building ............................ No. of persons............................ Showers ( ) - Cafeteria ( ) a � , Other fixtures --------•------------------------•-•-------•------••----------------------------------------------------------•-------------•------------•---- W Design Flow.................... .....................gallons per person per day. Total daily flow...................3.30..........._......gallons. WSeptic Tank—Liquid capacityd.,Kjallons Length. .'b"...... Width.4_11D11__- Diameter................ Depth..aI8".._. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------ -_.__... Diameter.&r 511..__...__ Depth below inlet......6.'......_.. Total leaching area----- QD_......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.... .........•........ Date..FS.1518D....................... Test Pit No. I.....I-------minutes per inch Depth of Test Pit----------�2.._.._ Depth to ground water..............:......... . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ----•------------------------------------------------------•----------..._..................-•_...-•.......................................................... D Description of Soil......2 ---eOCtm 9•4.0,5o�,�---2-4t..b:i.Q, c�.bCiV�d,---4-"- --•-------•----- x ----- ------------ -------------- W --••---•---•-------••--•••-•------------------------------------------------------•------------------------------------------------------------------------•-------•-------...........-•--•-•-••-•-•--- UNature of Repairs or Alterations-Answer when applicable................................................................................................ -------------------------------------------•-------•----•---------------------------...........-....---•-----•----------------------------------------------------•---•------•••-••-•••••...--••-•...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT LE 5 of the Statee-anit�ary Code The undet-signe per agrees not to place the system in operation until a Certificate of Compliance has been issu e board li Si A......... r /t�" - ------• , -----------•------------------------- ----------- --------- � 9 Application Approved By..... r=� ��`,-. � .:.. - Date Application Disapproved for the following reasons:................................................................................................................ . ..............................................-•-•-•••-••-•------•---•••-•--......---••-••-•••••-•---••-............................................................................................... Date PermitNo...................................................................... Issued- '._7_�. --------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �... ./..� ..........OF.........Z. !Jl, ........................................... Tnr#ifirFa#r of Tomph anr�e THI yIS TO ERTIFY, That the Individual Sewage Disposal System constructed ( r epaired ( - ) by......... nst ler`, /! t /�;/� / f 1 at.... �Sr� 9/J�._G�/.F:� ... e�✓f.___ /_t .. f. .___ _IScZ% t..._. \ -Fe`:...- �1..i.. _�____ has been installed in accordance with the provisions of T f'IPEE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. .............. dated__-.-._��':`: .: ;U................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ® AS A.GUARANTEE THAT THE SYSTEM WI L FUNCTION-SATISFACTORY. DATE...... • -•V--•-•-•-----•-•--•----•---------------------- Inspector---...... .. ............................. THE COMMONWEALTH OF MASSACHUSETTS '1 BOARD OF HEALTH 5_4,44 Nv- ...... .--- L FEE.... : ............. io oottl ork woni#r ion rrmit Permission is ereby granted........... •. •-------------------••••-•-•---••••-•--••••-•-•-••-•---•••--•.....•••••--•-----•-........................... to Consgtr"ct ( )/or . e air ( ),a Iivirival See Diposal_Sstem 139 at No.-S� � 1��v �" .._.._..pC ... s -'��-=� . •- `•----- ........... ------- Street � as shown on the application for Disposal Works Construction Permit A�o_____________________ Dated......__%_'............................. /�'� ��/ board of Health DATE .......... .......... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .._._� `tit=-r tC f�.l� T7�:1 r^-�`. _�_----- ----�=•��--- ._._ _._ ,... _ _ _'__"_'� _ -- _ _ _ __ _ Ido i ►i�� c=t �w _ IIU G•P•D• 3So,r ISG `7. - 4-9 cj USA- L 00c3 lc�C- SF �c 2.S� 4 27r> xr-T-o�vU AIZCEA._ r::;0 sr. I c> _ Sb 1 TOT,&L 't;)ESl6KI = 4ZS G.P.D. ToTAt_ lc>,&lt_`( 6.W. 11"lGDLQTlOt.l C2eTE l �� Z�4(tu Olz U_ jQeOK "` L�oP �•� .- .,.c .w*� �Psi'� S•9�, / /^ �'\ TANG ft"voo 'Tr--,T almll a d�u � I ao0 11lV. 4 Z,4- �JPfivi� -Box QZ. Sa`vric IWV. 'TAWK 2 �Z 1Do0 dl.a �uV UN. GAL. 4t,L 41.B LAN A PIT �! SA i l WAS►1ETa STOWEE-- �50 C- QT FU.'5T FIL.A," l VOT---it_E: >_oCATt0" ter !Z 1 I O SG o.I.�- G'2 C A LJ�_ /N J A--T o W4T6- -- izoperit t c G rz T I p%4 T I--(A T T N G i�wt Y.s.+w1 l,, 5 c lotiv►.) Pt.A i.,! R r F E R ►.1 G� t-1C:�,c t�e,l �catitPL�IS WIT" lS.L.ID ��T�AGtC S'C-Lt�c.�lC�'EN�c:NTi OF: TNfr -TOW Li Ot= 13p2� T' L-eS PLAW G:O2 ALAQ S. ' ,54A4!_1_.. PATSO t eC.t ry cx> 1.A.1-1G SUZv�.YacZa ►-1 Ul AS�[a 064 4" O�'t c k'_V L l-Lr— C.) �trC SS --I'tGwua 11;L; 1 i l�I=�1"t_G_M c►,!tr l_ca't i_I Nei i - - cV?.t! It3 w"_ TOP OF FO UNDA TION EL LA-I -Z. GROUND SURFACE EZ__ STA - A R.,' GROUND SUWACE EL_ ----------------------- J) TffJS PLIN:IS M 77JE--NSTXtW%r,1 OF A SXP17C SYS7EA1 OUTLET PIPE LEM ' 7 ALL LYSTALLA 4N PROCEDURES AND AN TERIA1,S SIALL COATOP,11 TO 1,310i��CW 15 000,',TWE,STA 7D LA ROMENTAL FIRST TWO FEET, PENT REQUIRED , : I : , ; I I - � I l�,k I t� , C01VE QUID LEVEL TOP EL D iVE TOWN,OF It 4 SUBSURFACE DISPOSAL ��REGULATIONS_ 3) A0 DETERWATA iON HAS BEEN IfADE AS �TO COLUTLIANCE OF A VA-)ZABIS TWORERTY IXFO"A TION HYTH.RECORDED DEMS ! , N 2' LAYER DOUBLE WASHED 1/2' STONE 10' INVERT EL 14" OR ZONING RPr ULA 77ONS. 4) TOWN W417R ,5�R VICES PROPERTY EFEWNVE GAS BAFYZE AT OU7ZET 7 'LLS' ON TH137 PROPERTY OR HTTWZAT 100 OF THE PROPOSED:,SOIL, ABSORPTION'S YSTEM. S.M.EvArZ 5 H ANO WY PRrVA TE WE Li o INVERT EL JN T ERE ARE N4 VERT EL INVERT EL 8) ALL COVERS 0) SYSTEM COMPONENTS SHALL BE BROUGHT TO #7THEV Ile, ,OF FIATSHED GRADE, , #7TH ONE COVER OF THE, j" SEP 7 7C TA NK )17TJVN 6 OF GRADE 3/4'— 1 1/2' DOUBLE D - Box J�OUGHT INVERT EL S (Typical) VASHEDSTDNE ., SYSTEM C,��L REMAIN ACCESSIBLE JrVR INSPECTION. ��'NO STRUCTURES SHALL'BE LOCATED''DIREOPL 6" STONE BASE INVERT AZ 7) ALL WHICH ,WO UL D _ACC 5�>o Gal Septic Tank PON OR NTH PHE .AERPORMANCE, ZSS, 1AFSPECTION 1 ,U � .TF�E COMPONENT ACCESS LOCATIONS, W BOT7VM EL J�P PUMPINC OR AL't (Typical) 10 NO DR] SHALL BE LOCA T&D, A190 VE :A SOIL ABSORPTION 04AYS mUNG OR 'TURNING AREA, OR 0 THER IMPER WO US A R EA 1 _rt AJ 8 -BOYTOM OF TEST HOLE' WHEN. VEATING HAS BEEN PRORDED., J— EL_ SEP TIC I GREA SE TR A PS, DOSING CHAMBERS AND DISTRIBU77ON B6, A -6, SY19AW BASE ., iiS SHALL :B8"PLA CED ON T E AAD ,PREVKNT SE77ZLVG. 0 NS UREE we, -OF THM LENGTH. .10) OUTLET" UTION,LINES SHALL REMAIN LEPIEZ, FORA MINIMUM OF:Ir2W FIRST,tTWO FEET 11) ''ALL SYSTEM SHALL BE CAPABLE OF ,ff1TH37AArDIWG:,H-10',LMAWC, HEY-ARE UNDER OR KTAIN 10 6MPOkENTS �T -C �SHALL BE OFDRMEWAINDR PARA7NG OR TURAVNG 'ARE"), !IN WHICH ASE H---�20`6 J ALL BUILDING WER LJX&S SHALL HA VE AN .LVAWR DIAMETWOR,J4 �4ffi) SRALL' BE,�CAST-JRON,dR SCHEDULE -PVC : ',' 40 A EA" 'H N N G A,:��,B E -COM THE 'DEPTH OF,,TBE TOP OFALL SYSTEM PONENTS SHALL�NOT_E2C61ZV,­36 UNLgSS PRO P75E 14) IN =TING �:AAFK,W 0 F UCA VA TIO Ns GRADES SHALL BE REESTABLIS11ED ONLESS' NOTED AS_'PROP0S6D '6dNT61U�S -A 15) H SOILS ARE kVt!0UN7ZfiEV DURINC THE EXCA IVAT ON OF T SOIL� BSORPTION.SYSTEM, THAT DiFFER NorABLY FRom T ME -ENGINEER 7VE ,DPj6T ORSER VA TION HOLE,WQ, CONTACT BEFORE PkOCEEDING. ' 16) CONTRACTOR VE RIFY LO CATION OF,ALL UNDERdROUAD Un Z ITES, V, N� V 00 N 88 V2,'45",E 303.9 7 DESIGN DATA F IN PtEP. OBSER VA T,10N Number of Bedrooms: LOG , 50 X0 T xt� Ole ,#I Garbage Grinder: son Design Flovr �i4b In. Nxt r of (USDA) Numbe BR) (110 Gal/BR/Day x DRAINAGE EASEMENT a Septic T nk: tA 'Design Flow' 'x 200%) um.= DAM Y , a: Leaching Are 5A _(Minim 7. 19 90 4 � 4 V Sidewall: x t) + (2 Side lis — - i _LF TBAf EL - 472' N, - Top Fbundation � l 67� _j om: �D@ 0 , Z Endwalls x t x zWst1nk B6tt 041,Survey voirpum t7,�"Ire* 1,500 Ga 1 0 G601000 1daterlsk ;Depth�Ah,:Standlng Water. NA Septic Tank 01 4171 x Ft) (o Depth t o��,Vaeping Water. to Color)- -��'NA 'Depth I Notalud I �,� ': -,Ra Efft Sewonal h GW­ �1: ptance' NA V Term Adee & LO N well::,� A V usGS-0 11 Y. MA - aching , Ar ea, esign� �Capacit M�jst Pit Data of 1�mt pump an t ed , d �'tSid �C h* Cz V , _1__,, 0, k � I cl ewall Are� + Bottom ,Area) x LTAR as� req Q Loc Test Pit N ation Prop stink Garake D-Box .10 40 6 :�z ROPOSED AC ACHINGIP IMTY R LE Four 4.67' 8.5�r 21deep 'concrete x cbaw &.m wltb 4' stone, on sides h and ends A ;IVZ4, � ,4 PROJECT IOCA TI6Ar' A14 74 A A ASSESSORS�.MAf WTI' jk4 C A T',, P Q? N mot'. %`4 Ali t\_1 A PREPAREL �BY 0 C_u.5 d: "S6 -"Lan ces e 5,�Srun.�rd t So u ,,Yar!h2o&th, ` A '02864 508 ��394��R 23 L i Ar A AM. 0 J,' TP. '5C "41 �,,REV 'LOCUS .MAP , - �"YW �30 1A 5 Nt i L G) S 5 'OTY IONT