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HomeMy WebLinkAbout0030 PEONY LANE - Health 30 Peony Lane_ Marstons Mills A = 042 026 I TOWN OF BARNSTABLE LOCATION 6 *h,1Q L a`-( � l'!�l�L� SEWAGE# n SCG+� VILLAGE 1h y Yb ASSESSOR'S MAP&PARCEL O pup SEPTIC TANK CAPACITY LEACHING FACILITY- (type) (size) NO.OF BEDROOMS C OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY hand-sketch in Me area below .. ❑drawing attached separately 1 TC o If! ill 6L 35; t,J aka - oa Commonwealth of Massachusetts - _, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -y 30 Peony Lane, Marstons Mills,:MA Property Address i x Angela K&Sean M O'Brien ' Owner Owner's Name ^' information is ' required for every Marston Mills MA 02648 09/21/2018 r page. City(rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer; REID G. ELLJS _ use only the tab _ key to move your Name of Inspector cursor-do not ELLIS'BROTHERS CONSTRUCTION use the return Company Name key. 23 ENTERPRISE ROAD W Company Address YARMOUTH PORT MA 02675 Cityrrown Stater Zip Code 508-36,2-6237 S121'891. Telephone Number License Number B. Certification I certify that: I am a DEP approved,system inspector in full compliance with Section 15.340 of Title (310 MR,16.000); 1 have personally inspected the sewage disposal-system at the property address listed above; the information reported below is true,accurate and complete as of the time of my inspection-, and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems,After conducting this inspection I have determined that the system: 1. 2 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving.Authority 4_ ❑ Fails Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or;greater,.the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc•rev-_7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1.of 18 r Commonwealth of Massachusetts - Tithe 5 Official Inspection Form 1} Subsurface Sewage Disposal System Form-Not for Vol untary.Assessments 30 Peony Lane, Marstons Mills, MA Property Address Angela K&Sean M O'Brien Owner Owner's Name information is required for every Marston Mills MA. 02648 09/21/2018 page. City/Town State Zip Code Date of Inspection C. Inspection .Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: Yes 12 l have not found any.information which indicates that any of the failure.criteria described in 310 CMR 1.5.303 or in 310 CMR 1,5.304 exist. Any failure criteria not evaluated are. indicated below. Comments: 2) System Conditionally Passes: 111A ❑ one or more system components as de cribed in the"Conditional Pass"section need to be replaced or repaired. The system, upon omoletion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", ".no"or"not determi led" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years Id* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or filtration or tank failure is,imminent. System will pass inspection if the existing tank is replaced wi h 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 han 20 years old is available: ❑ Y ❑ N ❑ ND(Expl in below): t5insp.dod+rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Commonwealth of Massachusetts -, Title 5 Official Inspection Form +, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 Peony.Lane, Marstons Mills, MA Property Address Angela K& Sean M O'Brien _ Owner Owner's Name information is required for every Marston Mills MA 02648 09121/2018 e___._ page. City/Town State Zip Code Date of Inspection C. Inspection summary(cunt.) 2) System Conditionally Passes(cont.)* ! ❑ Pump Chamber pumps/alarms not operational, ystem will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or igh static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro en, settled or uneven distribution box. System will. pass inspection if(with approval of Board of H alth): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replace ❑ Y ❑ N ❑ ND (Explain below): J— F The system required pumping more than 4 imes a year due to broken or obstructed pipe(s). The system will pass inspection if(with approva of the Board of Health):. ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): —A/ 3) Further Evaluation is Required by the Board o Health: ❑ Conditions exist which require further evaluati n by the Board of Health in order to determine ifs the system is failing to protect public health, s fety or the.environment. a. System will pass unless Board of Healt determines in accordance with 310 CMR 15.303(1)(b)`that the system is not functio )ng in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126/2018 Title 5 idal Inspedon Form:Subsurface Sewage Disposal-System•Page of 18 Commonwealth of Massachusetts 4 - , = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Peony Lane, Marstons Mills, MA Property Address Angela K&Sean M O'Brien, Owner Owner's Name information is required for every Marston Mills MA 02648 09/21/201.8 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) I FT ❑ Cesspool or privy is within 50 feet f a surface water Cesspool or privy is.within 50 feetlealth f a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of (ant! Public Water Supplier, if any) determines that the system is function!ig 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 tribullary to a surface water supply. ❑ The system has a septic tank and SA and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SA and the SAS is within 50 feet of a private water supply well. ❑ The system has.a septic tank and SA 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 anal sis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent.and the p esence of ammonia nitrogen and nitrate nitrogen is equal' to or less than 5 ppm,.provided that no oth failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: 'You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ I91 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ [g/ Discharge or ponding of effluent to the surface of the ground or surface.waters due to an overloaded or clogged SAS or cesspool t5insp,doc rev.7126/2018 Title 5.Official Inspection Form:Subsurface-Sewage Disposal System-Page.4 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h5 30 Peony Lane,Marstons Mills, MA Property Address Angela K&Sean M'O'Brien Owner Owner's Name information is required for every Marston Mills MA 02648 09/21/2018 page. CityfTown State Zip Code Date of,inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems (cont.) Yes No ❑ Static liquid level in the distribution box above outlet'invert due to an overloaded or clogged SAS or cesspool Eq/ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z'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 groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ tributary to a surface water supply. ❑ ❑'' Any portion of a cesspool or privy is within a Zone 1 of a public water supply well ❑ [ Any portion.of a cesspool or privy is within.50 feet of a private water supply well. ❑ ED," 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.] ❑ �i" The system is a cesspool serving a facility with a design flow of 2000 gpd-. Ud 10,000 gpd. ❑ 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. A// 5) Large Systems: To be considered a large systoln 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"o "no"'to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 fe t of a surface drinking water supply ❑ ❑ the system is within 200 fe t ofa tributary to a surface drinking water supply ❑ ❑ the system is located in a itrogen.sensitive area(Interim Wellhead Protection Area IWPA)or a mappe .Zone 11 of a public water supply,well t5insp.doc•rev.712612018 Title 5.Official Inspection,Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts f^ -- 09 Title 5 Official Inspection Form Subsurface Sewage Disposal;System Form-'Not,for Voluntary Assessments 30 Peony Lane; Marstons.Mills, MA Property Address Angela K&Sean M O'Brien Owner Owner's Name information is required for every Marston Mills MA 02648 09/21/2018 — page. City/town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any,question in Section C.5 the system is considered a significant threat, or-answered"yes"to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310-CMR 1.5.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No EB/ 0 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 l� 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, e;Iuding,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? 25' Q 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: E5" ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related.to .Part Cis at issue approximation.of'distance is unacceptable)[310 CMR 15.302(5)] l5insp.doc^rev.7126/2016 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1� 30 Peony Lane, Marstons Mills, MA _ Property Address Angela K&Sean M O'Brien Owner Owner's Name information is required for every Marston Mills MA 02648 Og/21/2018 . page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 14 Number of bedrooms (actual); DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 40 Description: Number of current residents: - Does residence have a garbage grinder? ❑ Yes [-'No Does residence have a water'treatment unit? ❑ Yes [B'No If yes, discharges to Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes 2No information in this report.) Laundry system inspected? ❑ Yes ET-"No Seasonal use? ❑ Yes ErNo Water meter readings, if available(last 2 years usage(gpd)): Detail: ol\ol & , /< nqrnvqM Vv rIF _ao C-7 wiq Sump pump? .{ ❑ Yes [A--No Last date of occupancy: rO t O C ct;1`r� �►'1S�X°Cs��iG'� Date t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts -- 19 Title 5 Official Inspection Form 151 _ . __ Subsurface Sewage Disposal Systeml Not for Voluntary Assessments 30 Peony Lane, Marstons Mills, MA Property Address Angela K&Sean M O'Brien. Owner Owner's Name information is required for eve Marston Mills MA- 02648 09/21/201.8 q every page. CItyrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial.Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.20:3): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): — - Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 syste ? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records. Source of information: - i Was system pumped as part of the inspection? P-Yes ❑ No If yes, volume pumped: 10c 0 -..-.- gallons How was quantity pumped determined? —�,-- Reason for pumping: t5insp.doc•rev.7/26/2018 Title 610fficial-lnspaction Form:Subsurface',Sewage.Disposal System•Page 8:of 16 Commonwealth of Massachusetts x - 19 Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 30 Peony.Lane, Marstons Mills, MA Property Address Angela K& Sean M O'Brien Owner Owner's.Name information is Marston Mills MA 02648 09/21/2018 required for every _ page. Gity[Town State Zip Code Date ofInspection D. System Information (cont.) 4. Type of System: Septic tank; distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Q Tight tank. Attach a copy of the DEP approval.. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes FkJ—No 5. Building Sewer(locate on site plan): Depth below grade: - feet Material of construction: ❑cast iron [�,40 PVC ❑ other(explain): , -— ;"t` Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): ' ►'n 1'c' h -_ S Ven fl-e _N0 CIO t5insp:doc•rev-7126t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-P©ge9 of 16 Commonwealth of Massachusetts -= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Peony Lane, Marstons Mills, MA Property Address Angela K& Sean M O'Brien Owner Owner's Name information is required for every Marston Mills MA 02648 09/21/2018 page. City/Town State .Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): >� t;c -- / Depth below grade: f �` g n • feet Material of construction: Kl'conorete El metal ❑fiberglass ❑ polyethylene ❑:.:other(explain:) If tank is metal, li ^: years Is age confirmed by a Certificate of Compliance?(attach a.copy of certificate) ❑ Yes ❑ No Dimensions: n G/te. X r� Sludge depth: 13 Distance from top of sludge to bottom of outlet tee or baffle 31 Scum thickness Distance from top of scum to top of outlet tee orbaffle 0 -- Distance from bottom of scum.to bottom of outlet tee or baffle How were dimensions determined?' — `Tc !Toe Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outletinvert, evidence of leakage,etc':): S-e rat G fgn11- 14, l.S F) L-e v o I /j -flt tee, p.n I-e� ,r —S C,�do d IVC2SS i� As, 01 k or D - t5insp.doc•rev.M6/2018 Title 5 Official inspection Form`Subsurface Sewage Disposal System.Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 30 Peony Lane, Marstons Mills, MA Property Address Angela K.& Sean M O'Brien Owner Owner's Name - information is Marston Mills MA 02648 09/21/2018 requiredd for every page. Cityfrown State Zip Code Date.of Inspection D. System information (cont.) 7. Grease Trap(locate on site.plan): ` V/fq 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 affle --- Distance from bottom of scum to bottom of outle tee or baffle Date of last pumping: Date Comments(on pumping recommendations, ini t and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet:invert; evidenc of leakage, etc.): 8. Tight or Holding Tank(tank must be pumpe at time of inspection),(locate on site plan): Depth below grade: — Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑other(explainj: Dimensions ----............. -------- Capacity: gallons. Design Flow: gallons per day_ 15lnsp,doc-rev.7126r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 1 a Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t f� 30 Peony Lane, Marstons Mills, MA Property Address Angela K& Sean M O'Brien Owner Owner's Name information is required for every Marston Mills MA 02648 09/21/2018 page, Cityrrown State Zip Code Date of Inspection D. System Information. (cont.) 8. Tight or Holding Tank,(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date ----- Comments(condition of alarm and float switc es,etc.): " Attach copy of current pumping:contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet inverttvc) �Vorko'w 1-e"J) 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.): ew t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Farm Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments 30 Peony Lane, Marstons Mills, MA Property Address Angela K 8r Sean M O'Brien Owner Owner's Name information is required for every Marston Mills MA 02648 09/21/2018 page. Cityrrown State Zip.Code Date of Inspection D. System Information (cost.) > Vfi 10. Pump Chamber(locate on site plan); Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamb(r, condition of pumps and appurtenances, etc.): ' If pumps or alarms are not in-working order; system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required):. If SAS not located, explain why p /zq -ed - - Type: 1 leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: - - - ❑ leaching trenches number, length:. El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -- -----____........... �_......._ t5insp.doc-rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 - - I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments > t� 30 Peony.Lane, Marstons Mills,MA Property Address Angela K&Sean M O'Brien Owner Owner's Name - —....._ _. information is required for every Marston Mills MA 02648 09/21/2018 page. City/Town State Zip Code Date of,inspection D. System Information (cont) 11. Soil Absorption.System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level.of ponding, damp soil,condition of vegetation,etc.): COVUr ('o: Cc-1cr Cg" g ll h S ao (�� Sin n►r,��_�r� '�,�� 12. Cesspools (cesspool must be pumped as part of ift Action) (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 hydr ulic failure, level of ponding, condition of vegetation, etc.): I t5insp:doc-rev.'7126/2018 Title Official Inspection Form;Subsurface Sewage Disposal:System:.Page 14 of,18 f Commonwealth of.Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 30 Peony Lane, Marstons Mills, MA _ Property Address Angela K& Sean M O'Brien Owner - -----.- Owner's Name information is Marston Mills required for every MA_ 02648 09/21/2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan),- / M ( V atenals of construction; Dimensions Depth of solids Comments(note condition of soil,signs of by Jraulic failure, level of ponding, condition of vegetation; etc): t5insp.aoc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of le Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 30 Peony Lane, Marstons Mills, MA .Property Address Angela K&Sean M O'Brien Owner Owner's Name information is Marston Millsreuired for every MA 02648 09/21/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage,Disposal System: . Provide a view of the.sewage disposal`system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.,Check one of the.boxes below: hand-sketch in the area below drawing attached separately ,r roe 13°2, � s-- 7 t5lnsp.doc-rev-7(2 M18 Title 5 Of TrJW Inspection Form:Subsurface Sewage Disposal.System•Page 16 of 18 Commonwealth of Massachusetts f _ -_ip Title 5 Official inspection Form. Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 4� 30 Peony Lane, Marstons Mills, MA Property Address Owner Angela K& Sean M O'Brien -- -_.__---- ..--------- -__ _..-._.......__::._._...:......__ .. Owner's Name ..-.......-------- reformation is required for every Marston Mills MA 02648 09/21/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 15. Site Exam: Check Slope I .Surface water rl �l Check cellar t'b C-e I.i�i r (f ji /1 G nc�` a El Shallow wells N//T Estimated depth to high ground water: P 9 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) El Checked:with local Board of.Health-explain: ❑ Checked with local excavators,.'installers-(attach documentation) [ Accessed USGS database-explain: ,q You must describe how you es ab►ished the high ground water elevation: - --------------- 9 � `e To r :3 o Before filing this Inspection Report, please see Report Completeness Checklist on next page. i t5insp.doc•rev:7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts - -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,J1 30 Peony Lane,Marstons Mills, MA Property Address Angela K&Sean M O'Brien _ Owner Owner's Name information is required for every Marston Mills MA 02648 09/21/2018 page. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ["A. Inspector Information: Complete all fields in:this:section. fi�'6.Certification: Signed &,Dated and 1., 2, 3, or 4 checked 2"C.inspection Summary 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed W'*"D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 orattached For 15 Explanation of estimated depth to high groundwater included t5insp.doc•rev.7126/2018 Title 5'Ofcial Inspection Form:Subsurface SewageDisposal System r Page 18 of 18 OWN OF BARNSTABLE LOCATION �f '��� ���'� . �.v. SEWAGE # �1` � 2-- VILLAG ASSESSOR'S MAP & LOIDq2-—016 INSTALLER'S NAME & PHONE NO. G� � � � $ SEPTIC TANK CAPACITY [,coo 'LEACHING FACILITY:(type) NO. OF BEDROOM PRIVATE WELL OPX UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE G ANtTED: Yes No � ^ �� �/U. -•i � c , . , � .. �' � �' ,� 2t , - . � � - , ��e . � �� s�, '� Fins ............ '.:rHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4aa� ---------------------- .......................................................... rb� Appliratiou for llhipwial Mirkii Tomitrurthin Vunfit Application is hereby made for a Permit to Construct (K) or Repair an Individual Sewage Disposal System at: Is ...... ................y.......— .................................................................................................. Location-Address or Lot No. ...................... 5.mlt. ................................ ......P sin y--4ttir..------..........-----•-------•-------........................ Owner Address ....... Mu----low ....M&................................................... .. ....... ............................. ......Mae_ Installer Address U Type of Building Size Lot.....1.3,,A44Q.....Sq. feet _�I.rxe.........................Expansion Dwelling—No. of Bedrooms.... Attic X4) Garbage Grinder (410) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow................................1;7 ....gallons per person per day. Total daily flow.............................�-�.;.Q..gallons. 1:4 Septic Tank—Liquid capacity.lUxa-gallons Length Width.-4.l—le. Diameter. Depth.5'_!::&.'.// Disposal Trench—No..................... Width.....____....__..... Total Length__...............__. Total leaching area....................sq. f t. Seepage Pit No..... _..-,C>......... Diameter._ . ......... Depth below inlet......4..or ......... Total leaching area..a97...sq. f t. Z Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed by... .................. Date....7 12-/A 6 1-.4 V.------------------- ---r.....I........................ 0_� Test Pit No. I---e---------minutesperinch Depth of Test Pit....../4........ Depth to ground water. ...... 0-4 �r4 Test Pit No. 2................minutes per inch Depth of Test Pit..._........____._.. Depth to ground w OF P4 ......................................................................................................................... . ............... 0 Description of Soil.... ems? .oi X ...S..T.A.E.L.PL..YH..N.E..N....... U .................. 1 l I :SVN...... W ......................---- - 4 --a ...................................................................... No 30244- U Nature of Repairs or Alterations—Answer when applicable.............................................................. ....................................................................................................................... ............................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the as been issued by the board of he th.system in operation until a Certificate of Compliance Signed .............. -- --- --- --- .... ................................. ........................................ i Dace Application Approved By ................................................... ------------------ .. ...... 4V 15 ........................ ................... ..................................4a!��Z/ -----_-------- Due Application Disapproved for the following reasons: .................................................................................................................................. ----------------Date PermitNo. .................................................................... Issued .................................................................. Date No.....a.X.-.Ze.3,J_ Ewa.....2._`2.A....... r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :.: ,:::i......................OF. :;.a:s:;.,'sr..4� r. Appliratilan for 11iiposa1 Works onsirnrtion thrmit Application is hereby made for a Permit to Construct (r,) or Repair ( ) an Individual Sewage Disposal System at: •. ..�r"`. ... '�. �.... .....s.... .. ............................. _ Location-Address or Lot No. ........................�_t.::S= ._..}��:._ t?.ti+. ':l......._..... ....... . ._.... 0��r;.`?.f...'—�4?2=?�.... ..._..._................_.._._......_................. ..... ..._ ..... .. wn�r Address a ; ', , .. .... . •. ..... :......: a ....r < /;---------....-----------.-..-------•--------------- Installer Address Q Type of Building _ ' { Size Lot...../ .. ?.....Sq. feet Dwelling—No. of Bedrooms......?..F � .......................Expansion Attic (�ifv) Garbage Grinder �) Other—T e of Building ....... No. of persons............................ Showers ( ) — Cafeteria ( ) a Q g Other fixtures .................................................................-•--•-•---•-•---------------•--•-•----•---------------------------------........----- t� e Tank—Liquid ca acrt _.� allons per person per day. Total daily flow.... -- gallons. W Design Flow .5 --_.g P P P Y• . Y .� .---------•--...----•------ --------- i" Septicq p y aS�_,.gallons Length.`Z'.',-,§...... Width..°.:-:1._ Diameter---------�.. Depth.e- ..... x Disposal Trench—No. ................... Width............... .r. Total Length.:_.._.......... Total leaching area....................sq. ft. Seepage Pit No..... ...... Diameter.. Z.(2..__._..... Depth below inlet.......... Total leaching area...'r+....sq. ft. Z Other Distribution box (X ) Dosing tank_( ) / ~' Percolation Test Results Performed by.... _,__��`:�.!:z 6.I........................................ Date...._1:��l I as Test Pit No. I....:�_-------minutes per inch Depth of Tes> Pit------X4........ Depth to ground wat ....... r3;4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground O Description of Soil...��J `T";F '-'='x? ,.ate? =: ?... ?........... _.. r .._....- STEPHEN '�G a . _ .-- ALL'YN- -- ram„ IA ..................................'_P:"I'9.-__�_G°'l.__•r.r !.........t_.134-a•.rC;yl,. -........_.........-----.._..............................._._.....__.. ... No,30216- H U Nature of Repairs or Alterations—Answer when applicable........................................................... ,egg --------•------------------------------------------------•--------•------•-•-----...........---..............---....------•----•-------•------•-••••---•-•-•••--•-•-•--=• OidAL.. .. ---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code-,The undersigned further agrees not to place the of health. system in operation until a Certificate of Compliance as been issued b the board Y P p Y Signed .. - °:.... -�.. �� ' .............................. ............---Date ---------------- ApplicationApproved BY ----------- - - ----------------------- ........---.......------....------ -- .-- -- ------ ---- Dace Application Disapproved for the following reasons- ..........................................------------------------ ------------ ----- ---------------------------------- --- ................. .................................. .................................................................................................................................................... -- . ----------.......---........ Dace PermitNo- -------------------------------------------------------------------- Issued ........................ ....................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 01.1er#tftra#E of 1XII-orttplt2arcre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ''°" ) or Repaired ( ) ,�C 7`/ ...........................................................---...--...------------. ............................... . Installer -..--,....--,f S' 'c��.- ....--./-- / --c ------------------------------------------- has been installed in accordance with the provisipns of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... . .... ... . ..... .. ...................... ........ Inspector ....--------------............... -----------•----............. --- --........----- -- THE COMMONWEALTH OF MASSACHUSETTS BOARD" OF HEALTH .......�.c� c�.�............OF.....`�.:�. .r'� lr. ....................... No......................... FEE........................ %po,nf 014orbi �a. otr �n rrttti# Permission is eby granted. ; ......... •............. to Construct ( or Repair ( ) Individual Sewage Disposal System at �....., Eca.�............ ........................ Street as shown on the application for Disposal Works Construction Permit No.......:............. Dated.......................................... ..........--•--••-------••-------•------------------------------------------------------------••-------- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS D4/tom/ [w //OX 3 = 33� 6•Pi.7.. _ . . ��j�L�� �— ® 1 a/5 rS.r�L 5 top /70 70 5.=-x 2.5 �/S (:z..PD- •'c:::),V Via. 79.,5-�' x /.0 Gam. 7257-4L Pa4-�Z-y"CLOW OF .. STEPHEN .i� V r.•� ( ALLYN RiCH.�•.:)•A. \` �jlo Zb 11v WILSON BAXti �Cl 'cF' No.30216IST b NAL��6�� s>o FC/STEat�� ' J v�' i3 Q-J4 / S7;4L L I?G.G.9145C,e T. of FG• 8/0-o ,` FG. g" o s ///sue7.7 5,U Box /.VV (5AI , o• iT V.2 ?" � Il •; � �° 'tea_ g5`•� c.E,2r/F/E'O PGor� .o�:4N f Ss /Q r i4avA0000 b _78,0 Z� �`"' C• Z'.."'' Mc1�.v.�l ir��� LoG.�T/oy STb.✓S /[-C�$ k 1-14y'V2/4 L lc:be io A u. .5GeL6 •� L� p,4 T.E zc?' �w cL<Fr,=--!Z ppry / GE.6'71-,,'!:-)o00' THAT-T.yE 4v ax-c w- AiVO,SE'rl/ALY �2�QV/�'�N1�NrS d.� Tis'� .2.E'c5isrLSE'c'.lJ,L�trc/o.SU,ev .. /6 BORTOLOTTI CONSTRUCTION,,INC. �o 765 WAKEBY ROAD,MARSTONS MILLS, MA 026 RD 508-7711-9399 508-428-8926 FAX: 508-428-9399 �yo'9� f ON c9�d, cc SEWAGE DISPOSAL SYSTEM INSPECTIO PART A CERTIFICATION 5 Property Address: Date of Inspection: spec is Na ne: Owner's Name and Address: vy CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function aid maintenance of on-site sewage disposal "ems. The System: V Passes Conditionally Pass Needs Further l d htion ocal Aproving Aulhority Fails � . Inspector's Signature: / Date:- The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY• A)SYST M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria riot evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial 'infiltration or exfiltradon,or tank failure is inuninent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - y r . r + SUBSURFACE SEWAGE DISPOSAUSYSTEM INSPECTION FORM ! PART A CERTIFICATION (continued) ' Broken i replaced a '�^ P P pipe(s)F' Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply: The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private ter supply water PP Y well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the,presence of ammonia nitrogen and nitrate nitrogen_ a g is equal to or less_ than 5 ppm. y D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health. should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge im ga or ndin of efiuent 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 clog god SAS or cesspool. Liquid depth in'cesspool is less than 6"below invert bra vailable volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- i r SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within I00 Feet of a sm face water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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 titan WO Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliforin bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FALLS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or,more of the following conditions exist: 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 it of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMIt 5.00 and G.00. Please consult the local regional office of the Department for further information. •SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA[IT 11 CHECKLIST Check if the following have been done: !, Pumping information was requested of the owner,occupant,and Board of Health. v/None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As-built plans have been obtained and examined. Note if they are not available with NIA. ✓-The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ✓The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. V The septic tank manholes were uncovered,opened,and the.interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scun►. ✓The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- A­MA��,,a�v Tic 1 y ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART fl. CHECKLIST(continued) V The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "-SYSTEM INFORMATION—~ FLOW CONDITIONS BESIDE Design Flow: 0 allons Number of Bedrooms: �_3 Number of Current Residents: Laundry Connected To System: Seasonal User)o Garbage Grander: � ry Y Water Meter Readings,if ilable: Last Date of Occupancy / COMMERCIAL JINDUSTRIAi w Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System*Pumped as part of fnspeclioti: =` If yes,voluiue p need: »_ -° 'gallons Reason for pumping: OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of all components,date installed(if known),and source of information: Sewage odors detaited when arriving at the site:_��? - - -4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: "C-O'licrete metal FRP_Other (explain) _ Dimisions: •b "X& Y S' Sludge Depth: �' Scum'Chickness: o� " Distance from top of sludge to bottom of outlet tee or baffle: 3 �� Distance from bottom of scum to bottom of outlet tee or baffle: /> Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to o tlet invert,structural integrity,evidence of leakage,etc.) I,Z3 Q �Q/ /r GREASE TRAP: �d Depth Below Grade: Material of Construction:—concrete—metal FRP_Other (explain) — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or battle:—.Comments: (recommendation(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in'relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: galions/day Alarm Level: -` Comments:.(condition of inlet tee,condition of alarm and float switches, etc.). DISTRIBUTION BOX: Depth of liquid level above outlet invert: M� Comments: (note if 1 el and dist9butio is equ 1,evict a of solids carryover,evidence of I age i o or out of x,etc.) ezu PUMP CHAMBERc - Pump is in working order: Comments:(note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- A. VIM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con(inued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type; . Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil,signs of hydrauli failure leyFl ofpondijig,condition of vegetation, etc. 000 CESSPOOLS: 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(cesspool must be pumped as part of inspection) . Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) . _ .. . _..__ _ ... ._.... ._ _ ..`..tea...:.:»,_......�.._ _ .. -6 - it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (amlinued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or tx;nchmarks. Locate all wells within 100 Feet. ys' y y i i DEPTH TO GROUNDWATER: i Depth to groundwater: Z✓� Feet Method of Determination or Approximation: -7- No. a oo S - Fee ®o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS. 01ppYication for Migaar *pztem Conotructton Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 0 Complete System El Individual Components Location Address or Lot No. 3.0 pe0'l Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. las`4120-- q-1: ` Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) CV 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) z;o s f&// /2� u✓ ��_ /' X 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 Poard 9f Heal Si ed Date Application Approved Date Application Disapproved or the following reasons Permit No. �-� s—��� Date Issued —————— —— ——— — ———————— y No. / Fee / y �3 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH.DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for M.5pogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7 O EQ ���' O ne 's Name,Address and Tel.No. ��r.5ro�ls //S' 1v i1,e r Assessor's Map/Parcel D,L/,.;L. © 'a-. Inst let's Nam ,Address,and Tel.No. S 20" Designer's Name,Address and Tel.No. S �/oS t�� Type of Building: Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder( ) W Other Type of Building No. of Persons Showers( ) Cafeteria( ) r 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) rN$roll i 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 Jof Heattb. Si ned v Date_ t Application Approved b, _ . Date 3 -�P/ 5 Application Disapproved for the following reasons 1 Permit No. a —© Date Issued ` �,/�f 'CON1NfON ALTH OF MASSACHUSETTS , V ARNSTABLE, MASSACHUSETTS l (Certificate of Compliance PI—THIS IS TO CERT IFY, that the On-site ewage Disposal System Constructed ( )Repaired ( )Upgraded( ) Abandoned( )by ©J��A Z-� `'�'OS at Id G"0 01 has been constructed in accordance with the provisio s of Title 5 and the fo osal System Construction Permit No. � dated �G Installer ' Q �'"ram Designer �! The issuance o�lu's/permit shall not be construed as a guarantee that feystem Date Inspec _ No. �J —0 q / ------------ ------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1=igpool *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair K)Upgrade( )Abandon( ) System located at ja /'eaH ,4wy/; S ^115 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 rqust be completed within three years of the da of thi Meit. Date:_ Approved by TOWN OF BARNSTABLE LOCATION-�Q ��^�� �/J SEWAGE # 7-'4 4MLAGE YMW-5-1b,15 �'h,'l�S ASSESSOR'S MAP & LOT NAME&PHONE NO r�cl� d,�„/� qZ& l TI SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) ` (size) k000 � NO. OF BEDROOMS . L, i BUU-DER OR k Q PERMITDATE: COM=UNEE 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 leaching facility) Feet Furnished by o� � COMMONWEALTH Q)4 + H OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION IAP ..._ PARCEL '�"L�6 � �C) TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 30 Peony Lane o Marstons Mills MA 02648 Owner's Name: Robert DeCarlo _z - Owner's Address: Same N Date of Inspection: March 16,2005 Job#05-52 C:j o I - Name of Inspector: PATRICK M.O'CONNELL = U Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD � r- MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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. approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system`�����.�N OF• _ Passes �� • �' _X_ Conditionally Passes =_ Needs Further Evaluation by the Local Approving Authority �"e Fa' 0 L co Inspector's Signature: Date: 3/16/OS r�miunua 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. Notes and Comments: Distribution Box deteriorated and leaking,needs to be replaced.Observed 8-10"of effective leaching in pit. ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 Peony Lane, Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 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: XX Distribution box deteriorated and leakin2 and must be replaced XX_ 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 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: T41a r% Inenantinn Rnrm ril;i,)nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 Peony Lane,Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 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: _ 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 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 trigger-.d.A copy of the analysis must be attached to this form. 3. Other: Titla C incnantinn Pnr 611;1,)nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 Peony Lane,Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: 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 %day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped —X Any portion of the SAS,cesspool or privy is below high ground water elevation. — —X_ Any portion of cesspool or privy is within 106 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 1 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 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 forma No_(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 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• 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. T41. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 Peony Lane,Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 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? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding 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 of the 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. X_ _ 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)] Titles C inenaetinn Rnrm 6/1 aiinnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 Peony Lane, Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—66,000 ga1.2004—71,000 gal.= 187 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): 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: Tank pumped every two years. Source of information: Owner 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 Other(describe): Approximate age of all components,date installed(if known)and source of information: Permitted in 1989 Were sewage odors detected when arriving at the site(yes or no): No T410 S incnPrtinn Rnrm Ail;/Innn 6 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: 30 Peony Lane, Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: V Material of construction:_X_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:8.5' long x 5.2'wide—1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liguid level at bottom of outlet pipe Tank scheduled to be Pumped after inspection. GREASE TRAP: No (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.): Titles C incnr rtinn Pnrm A/J,;/')nnn 7 i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Peony Lane, Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 TIGHT or HOLDING TANK: No (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: XX (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 hieh stains box needs to be replaced PUMP CHAMBER: No (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.): T41. C incnp�tinn Fnrm l.�1 ci�nnn 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Peony Lane,Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X—leaching pits,number: One 6x6 pit. 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.): Observed 8-109'effective leaching in pit CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: I, 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Titles G Incnartinn Fnrm ll1 si,)nnn 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: 30 Peony Lane,Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 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. Peony Lane Water service #30 35 30 44 52 40 45 Tit1 a G Tncnortinn I:nrm 411 ci�nnn 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Peony Lane,Marstons Mills Owner: Robert DeCarlo Date of Inspection: March 16,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 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: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and Town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.45 and topo map shows property above el.90. Titles Tncr�ontinn Fnrm�ii�i�nnn 11