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HomeMy WebLinkAbout0167 PEACH TREE ROAD - Health 167 Peach Tree Road (Marstons Mills) A=056-062 1 1 Commonwealth of Massachusetts 'W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form .- Not for Voluntary Assessments M 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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, use only the tab-; .1. Inspector - key to move your � ht I cursor-do not 314 �(�V use the return Ricky L.Wrig key. Name of Inspector B&B Excavation �y Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code " (508)477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a.DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ _Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/16/13 Inspector's Signature o 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. l5ins•3/13 Title 5 Official Inspection orm:Subsurface Sewage Disposal System•Page 1 of 17 fl Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M , 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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 Y2 day flow l5ins-3113 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 °M s 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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. I 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 GSM 167 Peach Tree Road Property Address Maurice Pickering Owner - Owner's Name information is required for every. Marston Mills Ma. 02648 12/16/13 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 El ® Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the.system components pumped out in the previous two weeks? ® ❑ 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? EI ❑ 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. ® El 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 Tide 5 Official Inspection Form:Subsurface Sewage:Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c ;M 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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•3/13 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 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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: Tank original to dwelling leaching upgraded in 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 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 working order no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. Sludge depth: no sludge l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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 septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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 appears to be structurally sound no sign of leakage. 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 z 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2)500gal ❑ 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 appears to in working order no sign of hydraulic failure.Leaching was dry at time of inspection. 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-3/13 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 GSM 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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-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 •'° 167 Peach Tree Road Property Address Maurice Pickering Owner Owners Name information is required for every Marston Mills Ma. 02648 12/16/13 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: Z hand-sketch in the area below [] drawing attached separately 60 � a F r` i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 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: >12 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: 4/2001 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 167 Peach Tree Road Property Address Maurice Pickering Owner Owner's Name information is required for every Marston Mills Ma. 02648 12/16/13 page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION Zf�7 4 �lee `101 ` SEWAGE # VILLAGE �� ���T ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. � � 7713r� SEPTIC TANK CAPACITY �'��✓� LEACHING FACILITY: (type) �� �� (size) NO. OF BEDROOMS BUILDER OR OWNER P P 5 / PERMITDATE: I O COMPLIANCE DATE: LI l r9 Pi JI k Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 fee of leaching facility) Feet Furnished by �� rr► No. Fee Fee `✓ R THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Mtgogal *pgtem Con5truction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System "dividual Components Location Address or Lot No. I/ �feGZ�l�/ Owner's Name,Address and Tel.No. c Assessor's (' bafy .5c 1"J�e Map/Parcel o - Co �<-t'� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(14� Other Type of Building of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //t2 gallons per day. Calculated daily flow 0!0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank VIZ/ Type of S.A.S. Description of Soil 3`✓�O'� �����' C`��� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this B d 94 Health. Signed Y Date V11 7101 Application Approved by Date LI- I P'y Application Disapproved for the following reasons Permit No. Date Issued Z/--17-0/ No.. Fee ,✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es/ PUBLIC HEALTH'DIVISION - TOWN OF BARNSTABLES Y MASSACHUSETTS V 0(pprication for 0i.5po5al *p5tem Conotruction Permit Application for a Permit to Construct( )Repair(f,/)Upgrade( )Abandon( ) ❑Complete System "dividual Components Location Address or Lot No. / J_., /n Owner's Name,Address and Tel.No. S Assessor's Map/Parcel Installer's Name,Address and Tel.No. Designer's Name,Address and Tel.No. �or,�ololfj' Co�.5�` 7 7/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/tQ Other Type of Building e^o. of Persons Showers( ,) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title I Size of Septic Tank /oOlj 94'� �/ill Type of S.A.S. h� Z yo Description of Soil 3-J o'e Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a-Certifi- cate of Compliance has been issued y this B d Health. / Signed t- �ZZ� Date Application Approved by C - Date LI- 1 Application Disapproved for the following reasons Permit No. Date Issued Lf—1 7-O l ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY that thg On-site Sewage Disposal System Constructed( )Repaired ( L.�)'/Upgraded( ) Abandoned( )by Y i& `- at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ?,Qa 1"Z 21' dated- Installer Designer The issuance/o/f this permit shall not be construed as a guarantee that the system will function as designed. Date y!d � V Inspector �( ,�v, ��aA .A O �-� � o=� --------------------------------------- No. / Z G� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwizpoml bpztem Congtruction Permit Permission is hereby granted to C nstruct,( )Repair( ✓Upgrade( )Abandon,( System located at lt/i 7 �Pl/Gh 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 e it. Date: !��/�� Approved by '� ,�-,: _� �� ... � : - O i �� ��' �� '� _ � �� I �� ��� � l� 7 �� NOTICE: This Form Is To Be'Used For the Repair Of Failed Se -tic Systems. Only: - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUMON PERMIT(WITHOUT DESIGNED PLANS) �2, �Or�p��/�hereby ce�'that the an Gcatt' on for dtsaosal works coa=uction permit signed by the dated concerning the property located.at 7 T ¢/sy�f /��eets all of the Tollowinz criteria:. V/1 fie:ailed system is connected to a residential dwelling oniv. There are no cotnrne:cal or business uses associated with the dwelling. ne soil.is classified as CLASS !and the oe--niarioa:ate i I_ s .....CE-� Man n or tqua.t :o. minutes .per .ac`h: There are no wetlands within loo of_ne:;rooesed--eDdc s�s'lem f� mere are no prrnate wells within.l=o :of rue ar000scd seonc s ae:h. • 7-2--re is ^�no mc:...se in flow and/or c ang_o in:use nroxs.-d fie:e are no va-ants,=usi._d or act-it The bottom.of the proposed ieacuing facility will not'm located less Lan five met above the mo-draurn adjusted,p—mmdwater able eleradon (Adjust the g—round-water.table.tssing the t=rimptor /method when apolicablej, . Lf.the S. -S. will be located with 2,30 fee,.of arty ve2tated wetlands. the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the rna.-drntrn.adh sed groundwater table elevation, Me=complete the followin-g. A) Top of Ground Surface Elevation(using GIS information) 3) G.W.Elevation —the MAX iUgh G.W. Adjusnneni. DIFFERr'NC BETWEEN A and B SIGNED : DATE: 4//71,1P1 (Sketch proposed plan of system on baCkj. T beam fr*ida CM% C-�I/ pLZCAi10N P.4i_ -BEDROOMS=,�Tuu c�3 dtsi=t _zDd. S I EWALL: —A.ao. -.id--$ 53.it :,idi�X,lean �O =;a.Z Boa:a area ' _"total ar�.a �� �-Z•. � o X '7 (appucon r^ae) _ailars/day YU I TOWN OF BARNSTABLE _ LOCATION (lg� eAChet� CZep SEWAGE# VISP VILLAGE 115 ASSESSOR'S MAP&PARCEL IN9*At4qERS NAME&PHONE NO. ` r (31-4 on V,0 Lea� 117 SEPTIC TANK CAPACITY 1000 ;J LEACHING FACILITY:(type) C (size) 1UXY0AQ NO.OF BEDROOMS OWNER— PERMIT DATE: CO?ffPt-h*+C-E DATE:`7x�SP. 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 leaching facility) Feet FURNISHED BY Peachtree Road i Water Service i I 2° i e ss 60 n ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments U 1 w 167 Peachtree R �M oad Property Address Maurice Pickering J Owner Owner's Name information is Marstons Mills MA 02648 May 29 2008 required for y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell _ cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B.'Certification I certify that I have personally.inspected the sewage,disposal system at this address and that the informa ion reported below is true, accurate and complete as of the time of the inspection. The inspection tf,UI r—was pe formed based on my training and experience in the proper function and maintenance of on site -rsew age disposal systems. l am a DEP approved system inspector pursuant to Section 15.340 of 6jitle 5 310 CMR 15.000). The system: -� sses ❑ Conditionally Passes ❑ Fails cry trs �w t �A ❑ Weeds Further Evaluation y the Local Approving Authority I May 29, 2008 Inspgctor's SignatL 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. 08-135 Pickerirg.doc•08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is Marstons Mills MA 02648 May 29, 2008 required for y every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching system has no standing water or sidewall stains. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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',sept c tank mill.pass inspection if it is sti ucturaily sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ 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 ❑ obstruction is removed 08-135 Pickerirg.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 t Comrnonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is Marstons Mills required for MA 02648 May 29, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 tl'te 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 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. 08-135 Pidcering.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 167 Peachtree Road Property Address Maurice Pickering Owner Owners Name information is Marstons Mills MA 02648 May required for y 29, 2008 every page. Cityr town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 El ® 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. 08-135 Pickering.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 'Come ionwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 167 Peachtree Road Property Address Maurice Pickering Owner Owners Name information is Marstons Mills required for MA 02648 May 29, 2008 every page. Clty/rown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 08.135 Pickering.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owners Name information is required for Marstons Mills MA 02648 May 29, 2008 every page. CltylTown 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)] 08-135 Pickering.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is y Marstons Mills MA 02648 May 29 2008 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Inf ormation formation 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 Number of current residents: 2 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 Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage 202,000 gal. _ 9 ( Y 9 (gpd)) 276 gpd. 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: Last date of occupancy/use: Date Other(describe): 08-135 Pickedng.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 'Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is Marstons Mills MA 02648 May 29 2008 required for y , every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped last summer. 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Leaching system installed 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-135 Pickering.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 i� 'Comnionwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is Marstons Mills MA 02648 May 29, 2008 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 18"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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 211 Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 08-135 Pickering.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15 i� ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is Marstons Mills MA 02648 May 29, 2008 required for y every page. Citylrown 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.): Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank is not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 08-135 Pickering.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 -Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is Marstons Mills MA 02648 May 29, 2008 required for y every page. Cityfrown State Zip Code .Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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.): No solids or high stains present. Liquid level at bottom of outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-135 Pickering.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is Marstons Mills MA 02648 May 29, 2008 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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:. Type: ❑ leaching pits number: ® leaching chambers number: Three 500 gal drywells. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching chambers were found empty with no sidewall stains. 08-135 Pickering.doc-08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 i 'Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is y Marstons Mills MA 02648 May 29 2008 required for , every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 08-135 Pickering.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 i f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is required for Y Marstons Mills MA 02648 Ma 29, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal 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. Peachtree Road Water Service J / / / %/%/ /%/%/ / / I / / / / / I%/%/ r % / %!%/ / / / r%J%/ / J / r / / r r / J / / / / / / r / / / / J / / / / / 29 ao CD 20 69 60 71 •� 'Comnhonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Peachtree Road Property Address Maurice Pickering Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface-water. - ® Check cellar ® Shallow wells Estimated depth to ground water: 20 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: USES topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 20 and topo map shows property at el. 50. 08-135 Pickering.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i Town of Barnstable o�tHe r " Regulatory Services IARNSTABLE, « Thomas F. Geiler, Director 9� 6 9. ArEo ,�A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have. any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:ISEPTIC\Disclaimer Private Septic Inspections.DOC S1i..fGLE FAly\lL�( - 3 T3�2.00M LAO G<.crscr-E C>ie{ p,&l L.�4 FLOW _ l tO.,c -3 t 33o �ET-ir_ �T •�+-tiL = 33QJ I�� % • 4��,6.P•v. USA- l QOC, GAL-. •Dt5P05A..1- PiT - usE I coo GAS. Z'(T.�LtJQ I!✓ AczEA = (5D S.F. -C IC7C7 SF )c 2.S ToTAt_ L�EStGtJ = d25 G.P.D. ToTa tr flat��f Fc ow = 330 6.PD. �� '. ti +D t tdGDL�TIOtJ tZI�TE : CIQ SMIQ 02 >✓\ \��` j�;t' .�` `� r -1 7,77,1 � (dGb {IN•. 4r�PB V�j( IyY. GAL. -Z _ / -Box t4 SEVI'IC I a IWV J Ta r11t tlwv, t►N GAL. p LEacN . , i PIT e: UN VC/1 T-0 WAu1ED �j p --- — tJo Scats C1�1_ .A.T� 4' u T 1-(A T T 14 t-1E:�'t_i7�J C�IPL`!S W ►TI-� TI-!� SIDE <Lt►-.lam ��� '� �.. ,�� Autz> 5ElrVACV- vcgUI QTs, oG TNT REGIS rc:tZEt-> t�Al.tC) ' OSTEV-V%u TW145 t��nN t5 uOT PA-S=.V U4 ! A&J G c� 1t.l�r�'Lf�►/��=.e.�1,' �,Uc�.��_\{ � TI.1L: c�F�:��-T'`, i1-�owt�D A��LtGA.t�1T_ Q TOWN OF BARNSTABLE LOCATION ��� r eAC� rCL 4C� SEWAGE # - VILLAGE M. MPYS, ASSESSOR'S MAP & LOTM 56 o6a INSTALLER'S NAME&PHONE NO. /0* SEPTIC TANK CAPACITY �OrtJL� LEACHING FACILITY: (type) PST (size) �� �� C-�t/• NO.OF BEDROOMS BUILDER OR OWNER SCE PERMITDATE: COMPLIANCE DATE: �a- 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 leaching facili ) � J Feet Furnished by �_ ro" Zn SOc�Tien �ll�/BUD/ A�_ ao• � g�- ac) Aa a3.(P WAI I Ba- 33' Al' 3 0 63- yo a Aq, 3�► Q4- sO' 3 Y -� lIAT ,�, CION �� SEWAGE PER IT N0. VILLAGE I N S T A LLER'S NAME i ADDRESS /2 BUILDER OR OWNER DATE PERMfT ISSY D DATE COMPLIANCE ISSUED zza r/ i ' / I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 167 Peach Tree Road Marston Mills, MA Owner's Name: Gary Scrupps Owner's Address: 146241531d Street East Orting Washington 98360 Date of Inspection: April 5 2001 Map:056 Parcel: Name of Inspector:(Please Print) James M. Ford Lot. 14 RECEIVED Company Name: James M. Ford Mailing,Address: P.O. Box 49 APR 13 2001 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 ; ,_ • TOWN OF BARNSTABLE HEALTH DEPT. 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 function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Ne s Further Evaluation by the Local Approving Authority ✓ Fail Inspector's Signature: Date: Apri16, 2001 The system inspector shall sub 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'. Notes and Comments ****This report only describes conditions'acthe 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., Title 5 inspection Form 6/15/2000 Pagel Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 167 Peach Tree Road Marston Mills. MA c 'i Owner: Gary Scrupps Date of Inspection: April S 2001 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: «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. ;Answer-yes no or.not,determined(Y;N,ND),in the,- 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obsfriicted pipe(§). The system will pass inspection.if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 167 Peach Tree Road Marston Mills, MA _ Owner: Gary Scrupps _. Date of Inspection: April S, 2001 - 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 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: ' r, 'The system has aseptic 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 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. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 167 Peach Tree Road Marston Mills. MA Owner: Gary Scrupps Date of Inspection: April S 2001 D. System Failure Criteria applicable to all systems: You must indicate either`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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ An portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface Y 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 it 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.] Yes (Yes/No)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 System' To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 167 Peach Tree Road Marston Mills, MA Owner: Gary Scrupps _ Date of Inspection: April S, 2001 i 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?; , J Was the site inspected fot.signs.ofbreak out • ..nY: .—. ;�. ,. .. • - _ - � ., cur ___... .__- - ✓ 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: Yes No ✓ 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(3)(b)]. •• • . ; r, • .. Y ..i .._ .. ... Y .. � C. • L... .Y... !A•Y 1.,.r 1J r 5 • Fi Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ':.SYSTEM INFORMATION Property Address: 167 Peach Tree Road i Marston Mills, MA Owner: Gary Scrupps Date of Inspection: April 5, 2001 FLOW CONDMONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a 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 . Water meter readings,if available(last 2 years usage(gpd)): 2000- 79 000,gals.; 1999- 121,000,gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based.on 310 CMR 15.203): _ . ..._ _gUd...... 'Basis of design flow(seats/persons/sgfft,etc.): <- Grease trap present(yes or no): Industrial waste holding tank present(yes or no) s , Non-sanitary waste discharged to the Title 5 system(yes or no):. .• Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None on file-per treatment plant Was system pumped as part of the inspection(yes or no): 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) .Tight Tank Attach a copy of the DEP approval (describe): 'Approximate age of all components,date installed(if known)and source of information:. Oct 27 1982--per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SSYSTEM INFORMATION (continued) Property Address: 167 Peach Tree Road Marston Mills. MA Owner: Gary Scrupps Date of Inspection: April 5, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: t. Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 24" Material of construction: ✓ concrete _metal fiberglass _polyethylene _other(explain) If tank is metal list age:_ . ..Is.,age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qa1. _ Sludge depth: 6"+ ._. Distance from top of sludge to bottom of outlet tee or baffle- Scum thickness: 15"+ 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: Measuring 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.): The tees were present The liquid level was at the ioint seam. The tank was leaking. Scum and sludge levels were high. GREASE TRAP: None (locate on site plan) Depth below grade: 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: , Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity;liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - ' SYSTEM INFORMATION (continued) Property Address: 167 Peach Tree Road Marstons Mills. MA Owner: Gary Scrupps Date of Inspection: April S 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): -DISTRIBUTION-BOX:='' ✓' '(if.present,must be opened)(locate;on site plan) Depth of liquid,level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level Solids were present There were signs of backup from the leach pit The scum line was above the outlet pipe The D-box cover was 30"below grade. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): __ } Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: 167 Peach Tree Road - Marston Mills. MA r Owner: Gary Scrupps Date of Inspection: April S. 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1-6'x 6'(amount of stone unknown-no records) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: -- overflow cesspool,number: -- ---. Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation; etc.): The pit was dry The scum linema's uy to the.cover .There were signs offailure and backup. There-w_as-6":ofs1udQe on the bottom The cover was Y below J;rade CESSPOOLS: None (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: i Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 167 Peach Tree Road .,. r- Marston Mills, AM Owner: Gary Scrupps f Date of Inspection: April 5, 2001 Map: 056 Parcel:062 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 14 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. 3 � B WAI b 93 - 33 3 ✓-�3- 30 131- yo ley- 3-1 84- So Y 10 Page l l of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 167 Peach Tree Road Marston Mills. MA `*. t, • _ Owner: Gary Scrupps ^ Date of Inspection: April 5, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high groundwater.elevation: The bottom of the pit to'Qrade was approximately 10' Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 35'.+/-to groundwater at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11