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HomeMy WebLinkAbout0029 PREAKNESS WAY - Health 29 PREAKNE S WA Y AY Marstons Mills / A= 151 - 081 c Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments \ � 29 Preakness Way " Property Address Walter Campbell q Owner Owner's Name information is Marstons Mills t✓ Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information <5!#/�f0LJO y$ on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Q Company Address Sandwich Ma 02563 fiff City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ■❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey o�"m'" �� �o°o amo.�, ,..a�,� .,,,,�s 8-8-19 Oete:3018 08.1212:]8:58OIm Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �m 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments f; 29 Preakness Way V� Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 t 8-8-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System,Passes: ❑■ I have 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: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts �v Title 5 Official Inspection Form I1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 29 Preakness Way Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way L� Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ El Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ O The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way u� Property Address Walter Campbell Owner Owners Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (Cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ Q Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ El Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ a Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ El Existing information. For example, a plan at the Board of Health. ❑ ❑ 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)] l5insp.doc•rev.7126/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f' 'P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 29 Preakness Way Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 3 Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: No design plans were on file with the Board of Health. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes Q No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: ***2018- 50,000gallons 2017- 54,000galIons*** Sump pump? ❑ Yes ❑■ No Last date of occupancy: early AugustDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 29 Preakness Way �V Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Offdal Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way v� Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1993 per asbuilt Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 31 Depth below grade: feet Material of construction: ❑ cast iron ❑Q 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form I +� p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way u� Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ❑■ .concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 12" Sludge depth: 24" Distance from top of sludge to bottom of outlet tee or baffle 511 Scum thickness 511 Distance from top of scum to top of outlet tee or baffle 11" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way V Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �n e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �/� 29 Preakness Way V Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 0 leaching pits number: (2) 6'x6' 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 L Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Both leach pit had 1' of standing water when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way u Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ■❑ hand-sketch in the area below ❑ drawing attached separately VILLAG;e�_c�Po�.Y et'vs��� . Jzir zs`�f �' .. As3fs74SOR,S MAP d. LOT s.EPnC,TAH1C..CAPAC2'S'Y 2;EA fi3iVC; g (size zvza 'rim`s ryi rics�Y, a-v x 'WE'L -r�x � s �C wA Rug aE "ox c3wrrtt GAY —�--... _ . sA-rso�tPfuursC .tssurs '- 'r- - ' V1lRtA?7CE C�itANTETJ:"x,+r$ No i i I a r, t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 k I Cy Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 29 Preakness Way v� Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope A Surface water X Check cellar 0 Shallow wells Estimated depth to high ground water: No GW @ 15'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) El Accessed USGS database-explain: topo maps You must describe how you established the high ground water elevation: Oliver topo maps show the property to be greater than 15' above ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Preakness Way V� Property Address Walter Campbell Owner Owner's Name information is Marstons Mills Ma 02648 8-8-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ■❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r , C TOWN OF BARNSTABLE ✓ LQC,ATION tL 9 'iE'e�l f�rv�ss ,,g l Ap —SEWAGE VILLAGE ASSESSOR'S MAP & LOT ` Q INSTALLER'S NAME & PHONE NO. ��;[) 1wc SEPTIC TANK CAPACITY�'d),qZ d'e LEACHING FACILITY:(type) (sue) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER f BUILDER OR OWNER J)A e__e,y DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes Nor �j+ 1 i i � I \� �' r TOWN OF BARNSTABLE LOCATIONV COY• C SEWAGE # p SAD VILLAGE W 1�ASSESSOR'S MAP & LOT ^j-Q '-®0 STALLER'S NAME & PHONE NO. �* C,� Q ti. ��• ��� A �MPTIC TANK CAPACITY t0 ej o QaQ QLEACHING FACILITY:(type) (size) D i O NO. OF BEDROOMS 3 PRIVATE WELL OR W BUILDER OR OWNER L, e1a e.� • S o l�o w �, I DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 30 41 VARIANCE GRANTED: Yes No i/ F�dn� 1 I 44 - - (16' 53 i I TOWN OF BARNSTABLE WQ� LOCATION SEWAGE # VILLAGE %-v ! %m&n ASSESSOR'S MAP & LOT r® NSTALLER'S NAME & PHONE NO. �� ���,�. ��'�• ��o�$ -�EPTIC TANK CAPACITY tQ y 9) . '4EACHING FACILITY:(type) B (size) O NO. OF BEDROOMS PRIVATE WELL OR U j WA BUILDER OR OWNER �„ �,� ,� • a k�O W s DATE PERMIT ISSUED: -2G DATE COMPLIANCE ISSUED: -,�® VARIANCE GRANTED: Yes No i/ --r 4 S�t No.. ..... ... . Fps. ..S.N...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for Disposal Yorks Tonstriirtion Prrmit Application is hereby made for a Permit to Construct ( �r Repair ( ) an Individual Sewage Disposal System at: ................L"' 7 �7 2 �+ e�s lo✓0.. v.-, a,- f7e // .� V✓' L3 a � :......... ...........r.... ..... -.._... ............... ........................ ----........ - Location-Address or Lot No. .................. - v ................. 1.3 r..._o. .s .fZ ....._..r.3. ....��`y.. .- -� ner ddress � Installer Address d Type of Building Size Lot.-__--2.! � 7-3-�...................5q. feet tcmpe,7 Dwelling—No. of Bedrooms............!3!;�........................... Attic Garbage Grinder .( _)_5P Other—Type of Building f No. of persons....... .................. Showers Aa YP g --------------------------- P �-}— Cafeteria k--r Otherfixtures ...........................7 --------------•--•---------••-------•-•-----•---•----•------------•-••-•••••-----------....-•--•---------•--- w Design Flow......................%6.- .......gallons per person pey day. Total daily flow------ a--®.....................gallons. e� W Septic Tank—Liquid capacityl_d!�d.gallons Length_._..__... Width..4 ......... Diameter................ Depth...�T..'...... .. x Disposal Trench—No..................... Width............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....__...._ ........ Diameter......_�._��... Depth below inlet....:S-. Total leaching area.. sq. ft. Other Distribution box ( Vy"� Dosing tank-t---f '-' Percolation Test Results Performed by.... �_-^% __Cf - _.. t 1= .. . ._ Date_.... 1.Z� ,r a� Test Pit No. 1----- Z.minutes per inch Depth of Test Pit.._.../. _.__ Depth to ground water.......J'_`f .!�` � b 44 Test Pit No. 2-----�L Z.minutes per inch Depth of Test Pit___-1..� .`_'.. Depth to ground water...... P+ O Description of Soil... ' 7-.�,a� ^� ..... x U w VNature of Repairs or Alterations—Answer when applicable................................................................................................ .. ..-----•-------------------•----------------------------------------------------------•---••-•---•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the oa of health. l Signed..... --- ��-L-=" --•--•----------• ....... ..�T.. f a t ApplicationApproved BY ----------..... . .•. ------ ....................................... -•-----•----. e - Application Disapproved for the f ollo ing reasons:--------•------•---------------------------------------•------------------------------------------••-•----•----• ----------------------------•----•--------•-----••---------••--------------.......--------•-•------....-- Date PermitNo......................................................... Issued_..................- ................................ Dattee l-- ---- s' No.. ...��2-.� Fizz . �- ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......OF.....E° ;. ., ..n `...--------------------------------------------------- Appliratiun for 11iipo, al Warkii Tonarurtiun ramit Application is hereby made for a Permit to Construct (v<or Repair ( ) an Individual Sewage Disposal System at: Location-Address ! or Lot No. 'f a_ ___ '_w_S:3__ __ __•s�',•• __;%�_- ,,... ,.ig.X.. (kitiner Address ... t ° ..� f ............................................... Installer Address Type of Building Size Lot__:.4_,,L7_,�,�_____Sq. feet Dwelling—No. of Bedrooms...........3___________________________Expansion Attic ,, Garbage Grinder 1„ ) Other—Type of Building 3 F = __.n_.__. No. of ersons______t Showers Cafeteria Otherfixtures ...........................=='.%:................................................................................................................ W Design Flow....................._�5's .___........gallons per person per day. Total daily flow..... _Z__ ......................gallons. WSeptic Tank—Liquid capacity)2�Xfj gallons Length. ...l,< _ Width_ ____z j�i._ Diameter________________ Depth, x Disposal Trench—No_____________________ Width.................... Total Length.................... Total.leaching area....................sq. ft. � Seepage Pit No-----------I......... Diameter......I_ ..._. Depth below inlet___ Total leaching area._ �:,� q. ft. Z Other Distribution box ( Dosing tank Percolation Test Results Performed 1 ___ Date____ , ' . as Test Pit No. L__._�.7___minutes per inch Depth of Test rt_.___ _ '__ e th to ground water....... ,t f"? ` 5 fi Test Pit No. 2..... .__2_...minutes per inch Depth of Test Pit---- ?':__ Depth to ground water------,?j.z'.:-:: --••-----------------------------•------------------------•---......-•-••-----••------...--•-•••---........................................... •-•------ O Description of Soil-----/ "-, - �; . A---•-• '" -'y `4= "' ....... ............... U --•--•------•-----•••-------------------------------------- ..._._._.......•-••-----...._----•---•-•••--•-•---•--•......---•---•---------------•-__...--•--•---•-•----•.._.._..•-------••-••--•-•-- W ....................-------............................................................................................................................................................................. UNature of Repairs or Alterations—Answer when applicable............................................................................................... .....................................................-................................................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. , Signed_. ... •--•-- --- �_ D_�a r . � te Application Approved B _ ".�_e_t._�_______ _______ _ ' _ - G___.. w. •............................ �te ��-'!*'? . Application Disapproved for the f oll0 ing reasons:................................................................................................................ ............................................................•------------•------------.........-•-------..__....-•-•--•----•--•-•----••---------•-----•-•---•---•-•------••--------------•---•-••-•--•--- Date PermitNo---------------------......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -°'. ^^':.<"2..........OF..: ...r..r ........................................................ Tertifirate of Toutpliunre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( Repaired ( ) r --- - . - •-----•---by. .% -------------------------Installer----a------•----/----�•--•----••••-•-' ------------------------------------------------------------ at-_ �-----,7--- "/— --; ��- Y•e -. s_ !7. .A-,ai > has been installed in accordance with the provisions of TITLE- 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.____.___------ __`_______ _ dated---- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE C�NSTRUE® AS A UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... .................................... Inspector............... ...................................................... �- 1 1)475 4HOL COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ]~� / :° -` .r°.....• ..........OF...P.. / ......,.�.. a• ....................................................... _,_._ No:..l..:.....::..! FEE. }::a........... �i Disposal Works Toustr ion erutit Permission is he eby granted__._./- �.�.�.,�.. .............. to Construct ( o -Repair ( ) an Individual Sewage Disposal System at No.__ T..... ` ,•"` -- !- ? _ _ _...... - - '` tr Seet as shown on the application for Disposal Works Construction Permit N _�:_ _ ___ Dated________.__. _t�,.:- �_._.... .--------.. o of Health -DATE............... . . •---�.7................................ FORM 1255 A. M. SULKIN, INC., BOSTON ram E TOWN OF BARNSTABLE LCICATION 1�,'1,9 y SEWAGE # VILLAGE ASSESSOR'S MAP Cz LOT INSTALLER'S NAME 6i PHONE NO. )4.4W/�40 YL �8.Cl 1�fiC� i SEPTIC TANK CAPACITYe[l��iA>� ,� LEACHING FACILITY:(type) (size) l NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DA= DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Jd !� VARIANCE GRANTED: Yes No I / � r r � th •r ' Flz$....�....3 n.: ...... THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH Barnstable Conservatioft DgaVn0M TOWN OF B A R N ST A B L E 8' sis ire n or Diri.pnial Wnrkii Towitrnr#inn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 2� Preakr�es Way Ceyiterville ..................... ....... ....... ........ --.......... .... Location-Address or Lot No. Dace W J.P.Maco�nber Jr.O cner Address Installer Address UType of Building Size Lot............................Sq. feet .., Dwelling-X No. of Bedrooms.................a-------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ---------------------------- No. of persons.--.--------.-------.-.----- Showers ( ) — Cafeteria ( ) 04 Q Other fixtures -----------------------------------------------------........-------------------------- ---------•••-•----•-------------•...-•••....----•-------..... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width.............--. Diameter--.-- ...-..... Depth................ Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------- ----------- Diameter.--................. Depth below inlet..--................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................•-- Date........................................ 04 Test Pit No. 1................minutes per inch Depth of Test Pit................--.. Depth to ground water........................ LT4 Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth to ground water..--.................... a' •--------------------------------- --------------- --•-------------------- •.................... ---.... ... -.------------------------ -._•••... •.... ........... .•- 0 Description of Soil............... e-j---------•-------------••------------- W .....-•----••..............................•••-•......-•••-•••-•-•-•-•-••----•••••••------------•--•---------------------•------------------...---•------------------••......-•--•........: U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ............•-•----••-••...............•---•--•--•-•--•---...--.....•-•--•----•-••-•...........--•---•••---••-•----•-•-----------•------•--••-•----•••••---------••-•••------.....•---.................: Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian has been issued the board of health. Signed ... .... C,r/•./.. .... ............... ..��.�E��. ......:...... Due Application Approved By .......... .......... ......�„[s....., .............................................................. ....... '.�" .:.(..�.Q .... Application Disapproved for the following reafons: .... ......................... ........................................ .......................................... ........................ . . . ..................................... ......... . . .... ....... . -- ........................................ . . ........................ ............. Permit No. .........�7--'3----.---�/� ..... .... Issued ........................................................D�e...... Dale t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE / App iration for Diripwial Wnrbi Toutitrnrtiun Fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 29 Preak,ies Wav de itervi lle ..............................•-•--•-----•--•-•---..._.•....------------------------.............. ----•---------•---------•-----•••-------•••--•••-••--......--••--•....._.......--••-----••-•-•---• Location-Address or Lot No. Da^etv owner Address W J..P.Maco• her Jr. Installer Address UType of Building Size Lot............................Sq. feet t--t Dwelling A No. of Bedrooms.________________3------------ ---------._Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __d W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length.-.............. Width......---------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results Performed by........ ................................................................. Date........................................ 0-1 ,.1 Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f? Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ....------•.....................•---•---••-•-----••------•-•-------••----------•----..............-•......................................................... 0 Description of Soil.............Sand..-&.-Gras_Pl...................................................................................................................... V ........................••-.................-•----•--•-•••-•--...........--------•-•...............----•----•--.........----....-------•-••-----•-----.....-•--•----..................---.....-•---...... -----------------------•-----._..__....-----------•----•----•-----------------...---•------- •---... . --_-- IIUD Vralib pi `c: 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 system in operation until a Certificate of Compliance has been its ued by the board of health. Signed1,:...W .f.`''e-.�................. ..._ 3....-.:...... Date Application Approved B - - �� � �- ..................... .......���...-1..~Q�.... PP PP Y V J ,�;. ...... - - Dm Application Disapproved for the following reasons: . .............................. ... .. ................ .. ...................................................... - ...................................................... . ... . . . ......................... -. ........... . . . -- ...................................... ........................................ Da Permit No. -- --- 3...----....,.../.�......... �-{/ Issued ........................................................... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C Croft ate of C ontlatia re THIS IS TO CERTIFY,.That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)K J.P.Mar_omb r Jr. by . --------------------------------------- ................ -------- ....... ................................................. ......................... ...... ' Insallcr at .......29 Preaknes...Wa�I...Cen.�er-.� lle.. _.................. ............. has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. -...13-77.....'�/t ..(. __----l- dated ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. o� --.---__.........-- Inspector ....._. ..4 DATE.........._..... ...9.-^.-1..c�-.-.../..��..............._..... p VVV __._... - ............................ - .. —_-----_-.------------- —_.---—---_---___—_,—_.---_—_—-------------_---_ ----� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $ 3,) NFEE........................ Permission is hereby granted...J,_P-.Macomber -Jr •-•................. to Cons u t ) or Repair (X ) an,Incl$vid-uIl1Sewage Disposal System rear es �nWav Cein at No------------------------ ---------- __.-----------•------.- -.-------------.------------------------------------------ ----------------- -....... ------------------------------..... street C� as shown on the application for Disposal Works Construction Permit No.,/.--?-.V`L/ Dated.......................................... •---------------------------------q-.�----...........------..._..--------------------- - --------- DATE. ......................................... Board of Health FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS i BENCH MARK : TEST HOLE RESULTS P#� � DATE WITNESSED BY �� /Y � � s'`�i ''� .C3• ©• N• r x � j TEST HOLE TEST HOLE 1 rd ,�- fa rC:�P 2 -jr EL / /�? m R-a/vm 7-7 XA Vv g,ar `_ . /L2GROUND L2GROUND WATER WATER �..L. v e ENCOUNTERED ENCOUNTERED � ' MANHOLES AND COVER TO BE BUILT TO O ���� �'�'� ELEV. TOP OF WITHIN 12" OF FINISHED GRADE cz o ��Z�o , S��T� D���l .� '•' '� FOUNDATION �-R v FINISHED GRADE MIN. 2 % SLOPE ��� tih• � ze' l �� �j �� _ . ---- '� n-a ...,.� "► 4 D IA . --- I A. P E R S --- - - - 4 D �' �� � � PI E M, PIP FI 2 I� MIN 2�� LAYER OF �-, ,_ — „ ,;.. MIN . PITCH I FT. � L�VE _ • MIN. PITCH ;rv� 1 r .•. 1�8';�2' PEASTONE •! ( p,�o�-• � �„ . �' ' i _�/ r_d.. � "�' I/,q j F T, /rklpo ^�.w. // ..�{,. 2 ' /!2..y/,j � � • • � j INVERT � . GALLON IN'V3RJ,,. 6"s P INVERT ' ® c~n� � p - • r �4 ; I Y2 D I A. 4 / : � INVERT EPTIC TANK INVERT BOX % C� -� �• � I W�u'tP-� WASHED STONE / FOOTING TO BE PLACED / ON A MINIMUM OF 18' OF _ INVERT . ,� © •: ` PLACE ON ,. � cro �.; ALL AR9UND . VIRGIN OR COMPACTED --a•.� FIRM BASE L ---- c7 ao � �,� f o a �— ? G SAND IO MIN• crn�� BOTTOM AT ELEV, /: � GARBAGE ( 20' MIN.) 3r � - GRINDER 4 DIA. PERFORATED DRAIN IP .* ITH 3/4" ELEV. ` TO 1 STONE PROF I LE OF GROUNDWATER TABLE (( :o DIWCT FLOW TO SANITARY DISPOSAL SYSTEM � ( NOT To SCALE ) DESIGN DATA • CONSTRUCTION OF SANITARY DISPOSAL BEDROOMS SYSTEM SHALL CONFORM TO THE MASS. DESIGN FLOW GAL ./DAY ENVIRONMENTAL CODE TITLE W LEACH RATE MIN. INCH (REVISED 7- 1-77 ) AND THE TOWN HEALTH DEPARTMENT REGULATIONS REQUIRED LEACHING CAPACITY : :lo • SEPTIC TANK, DISTRIBUTION BOX AND LEACH - PROPOSED t � `�- GAL/DAY ING UNIT TO BE OF REINFORCED CONCRETE : 2, S f, Z)� > MIN. CONCRETE STRENGTH 3000PS.1. REQUIRED SEPTIC TANK / oao GAL. MIN. STEEL STRENGTH • 20, 000 PS. I. MIN. DESIGN LOAD I N G : hl , .=" PROPOSED SEPTIC TANK = /000GAL. • DRIVEWAYS NOT TO BE LOCATED OVER SYSTEM UNLESS H2O DESIGN LOADING IS USED • ALL PIPES AND FITTINGS TO BE WATERTIGHT AND TO BE OF CAST IRON OR APPROVED P.V.C. HEALTH AGENT APPROVAL DATE SITE PLAN SHOWING PROPOSED CONSTRUCTION ZONING DATA LEGEND LOCATION WEST BARN STAB LE , MASS . ZONE TEST HOLE LOCATION � oPsN SPACi /N TZJ� 20N FOR : LE B EL- S 0 LLOWS D EV• CORP. DATE : iz _ _ — _ r. E �� � , REFERENCE • LOT 7• . . AS SHOWN ON REVISIONS :_9/�¢ 7 REQUIRED AREA — �43,SGo� ♦0890� EXISTING SPOT ELEVATION 17.6 _PLAN B001< PAGE REQUIRED FRONTAGE . _ _ [/SO) 37. 5 EXISTING CONTOUR — 16 REQUIRED FRONT SETBACK _�30� 3�.J PROPOSED CONTOUR 16 SCALE / �- 30' REQUIRE [ SIDE SETBACK : �So PROPOSED WATER SERVICE W REQUIRED REAR SETBACK ` PROPOSED GAS SERVICE G PROPOSED ELEC. 8 TELE E 9 T CRAIG R . SHORT P. E t • PROFESSIONAL CIVIL ENGINEER BUILDING INSPECTOR APPROVAL DATE 131 OLD ROUTE 132 , HYANN IS , MA. 02601 FILENO. i - (1402 t ( TELE. (617 ) 362 - 9411 ) SHEET 1 OF /