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HomeMy WebLinkAbout0039 REGENCY DRIVE - Health ,.39 RogendpDrive, ' - Marston Mills -— - — A=064 - 648 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Regency� 39 Re 9 Y Drive f, V Property Address - Debra Kelly o t Owner Owners Name / information is required for every Marstons Mills V Ma 02648 9-25-18 -.. 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 3350 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 s� Company Address Sandwich Ma 02563 City/Town State Zip Code rmm (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. ❑E Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-25-18 Inspecto Ignature 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.MM/2018 Tide 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 39 Regency Drive L Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive v Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �m @ Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments u 39 Regency Drive Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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 ❑ 0 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.7/25/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �v 0 39 Regency Drive Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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 ❑ a Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a 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. ❑ R Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E • 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ a The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive V Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 required for every page. City/Tows 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 El 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 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? ❑ O 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? E] ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? n ❑ 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? ❑ 0 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ a Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 coo, Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive v Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): !� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/gpd Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes E] No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes [g No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: "'2016-3,000gallons 2017-1 1,000gallons— Sump pump? ❑ Yes ❑■ No 9-15-18 Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 1B Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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.7r26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts i ,z Title 5 Official Inspection Form !- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 39 Regency Drive Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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: SAS installed 1983 with a new tank installed in 2006 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 21811 Depth below grade: feet Material of construction: ❑ cast iron X 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive V Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11811 Depth below grade: feet Material of construction: FE concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallon 11" Sludge depth: 2511 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1519 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form lol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 39 Regency Drive Property Address Debra Kelly Owner, Owners Name information is Marstons Mills Ma 02648 9-25-18 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 I _ Commonwealth'of Massachusetts �= ,to Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive �u Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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): Orr 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 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive v Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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 0 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: El leaching pits number: (1 ) 6'X6' ❑ 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 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k' 39 Regency Drive V Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. SoR Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The Ileaching was in working order and was dry with staining 3/4 of the way up from the bottom at time of inspection. 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 c� Commonwealth of Massachusetts +s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive v Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: 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 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive v� Property Address Debra Kelly Owner Owner's Name information is Marstons Mills Ma 02648 9-25-18 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: W hand-sketch in the area below ❑ drawing attached separately Asbuilt Ground water profile y 2' 8' 13 V'X V'` ft A >12' Deck A2-41'8" A3-48' A4-40' 62.47' >4' 133 50 3 134.40' Of @0 Ground water t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive Property Address Debra Kelly Owner Owner's Name information isz Marstons Mills Ma 02648 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ■❑ Surface water ❑0 Check cellar ❑E Shallow wells Estimated depth to high ground water: No GW @ 12'feet Please indicate all methods used to determine the 9 high round water elevation: El Obtained from system design plans on record 3-22-83 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. w Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.R26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 I Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Regency Drive v Property Address Debra Kelly Owner Owners Name information is Marstons Mills Ma 02648 9-25-18 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 t e 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 x a t5insp.doc-rev.R26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 :z TOWN OF BARNSTABLE LOCATION � 3 y l`?ey���y Ar�`v Q SEW.AGE# .2004- j-7 t;VILLAGE ./L( it/I, ASSESSOR'S MAP&PARCEL ® L/ 7, INSTALLERS NAME&PHONE NO. A A/0 SEPTIC TANK CAPACITY 13-00 4 LEACHING FACILITY: (type) A(;fT^�, (size) /000 y J' NO.OF BEDROOMS OWNER PERMIT DATE: 'r7�-a��'(��o COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Ta ble able 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 A Li zgi v �s ' f r New a 7,2 ifool k D-Alt G 7s • R. No. Fee 1� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for �Y!6po al *pztem Con5tructiori permit Application for a Permit to Construct(t,,�lepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. q e,5e s,(,j Or M,f'yl, -Owner's Name,Address and Tel.No. Assessor's Map/Parcel Q " C,�,1 d u y QtoV 3 � 3C,(� r . `08- lad- taa� Installer's Name,Address,and Tel.N . Designer's Name,Address and Tel.No. .c. M . nn, n Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No, of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank U C4 Type of S.A.S. Description of Soil Nature of Repairs o Alt tions( w r whe ap icable) 9d q el !� Date last inspected: O'k. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions gKitle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu V,1111;e oard o ealth. SignedDate_ Application Approved by G1M Date L119 t G,c Application Disapproved for the following reasons Permit No. P 0 0 --/7 Date Issued Wa l d 6 No. 7k ��+ ;/_.j,�'`�^�'a Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: v� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIPPrication for Migogar *pgtem Con5truction Permit Application for a Permit to Construct(V4epair( )Upgrade( )Abandon( ) ED Complete System El Individual Components Location Address or Lot No. -Owner's Name,Address and Tel.No. Assessor's Map/Parcel (D LY © 3 Q p o 3 �•(� � �� S � �a g- r�a� Installer's Namne,Address,and Tel.No. Designer.'s Narrie Address and Tel.No. Type of Building: Dwelling No. of Bedroomds _ Lot Size ' -a`j sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow _ gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Sao /Ci C4 Type of S.A.S. Description of Soil: Nature of Repairs or Alt.7Iyitions(Answer whe applicable) FeS ( C�.t/ l.Sd qi /r A//k.V f /� �/r.'�n , T L. d 6 lt>A, .s v Date last inspected: 1 � ( 0 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 issu d lyy this11Board of - ealth. Signed 1� / ' Date y io? ' CG Application Approved by GIN• C Date 9 Application Disapproved for the following reasons Permit No. Z? 0 0 A — Date Issued l 0 6 r --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS �kr k O l y- Certificate of (Compliance THIS IS TO CERTIFY,th t the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded ' Abandoned( )by at 2 9 oa D C u ,v P ✓ll, ✓►�r � f. has been constructyd in Accordance with the provis' n f le 5 and the for Disposal System Construction Permit No. �606 dated Y "2 1 U,6 Installer G%, Designer The issuance of this permit shall not b of strued as a guarantee that the system will funspti6nn,s,d,esigned. Date , Inspector — No. ��0 6 ' � I ———— f .Fee /o" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade )Abandon( ) Systemlocatedat of ,PnC(4 rr,e M.✓f'1rZ/(- __ 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: Const. ction�ust be completed within three years of the date of this- t. Date: �a /0 ` Approved by � 0/" r l � • w L'Oil T ION [WAGE PERMIT NO. VILLASE INSTA LLER'S NAME i ADDRESS t UIIDER OR O NER DA T ti PERMIT ISSUED I DAT E COMPLIANCE ISSUED a 1 -folk 'F��.� �� •yva�a 7�'nSb7�✓ vP-A&v t TOWN OF BARNSTABLE LOCATION .3`1 i2r,a-e SEWAGE# 07006' %79 VILLAGE . ,�/I, ASSESSOR'S MAP&PARCEL t y 0 INSTALLERS NAME&PHONE NO. Y A/o SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Cx,f (size) . 10005 NO. OF BEDROOMS j OWNER . PERMIT DATE: 4/ a _�� 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 I within 300 feet of leaching facility) Feet FURNISHED BY Li mod,apron 35 f •Vru. 7,2 A9 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer, use 39 Regency Drive -Marstons Mills, MA Sr 33D only the tab key Property Address to move your Arthur and Norma Erickson cursor-do not Owner's Name use the return key. 39 Regency Drive Owner's Address t� Marstons Mills MA 02648 City/Town State Zip Code November 1, 2005 Date of Inspection: Date 2. Inspector: David D. Coughanowr, R.S. Name of Inspector Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to S ction %340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ F ❑ Needs Further Evaluation by the Local Approving Authority cri .r- Cop mm AA �4J1 S November 1, 2005 Inspector's Signa ure Date cd3 a"V 3 The system inspector shall submit a copy of this inspection report to the Appr ing Au&, ritygoard of Health or DEP) within 30 days of completing this inspection. If the system i a sharet'systbm or has a design flow of 10,000 gpd or greater, the inspector and the system own r shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2229.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 s Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form A. Certification (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal 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: t5-2229.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form - Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 39 Regency Drive g Y Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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: 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 t5-2229.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r�M Subsurface Sewage Disposal System Form A. Certification (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank❑ y p and SAS and the SAS Is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5-2229.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form A. Certification (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes 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. t5-2229.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5of16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system, considered a significant threat under Section E or failed under Section D shall upgrade the system, in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2229.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'LAM B. Checklist 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection Check if the following have been done. You must indicate "yes" or"no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, including the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5-2229.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owners Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is lau ndry on a separate sewage system? [if yes separate Inspection required] El Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 99 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other{describe): t5-2229.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4�M C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City[Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 23+years. Certificate of compliance issued 5117183(Board of Health records) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2229.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): 1 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 ❑ Yes ❑ No certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 inches Distance from top of sludge to bottom of outlet tee or baffle Winches Scum thickness 1 inch Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? Design Plan t5-2229.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/To-wn State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or cut was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2229.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System P 9 P Y Page 11 of 16 Commonwealth of Massachusetts Title 5 Official. Inspection Form } Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2229.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: ❑ leaching chambers number: ❑ 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Leaching pit was uncovered and found to contain 46 inches of effluent in a six foot effective depth pit. I t5-2229.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form iG^M Sy`e C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2229.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection 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. LEACH PIT 3 LOCATIONS O ❑ D-BOX A B C 1 21.5 It 15 It 2 26 It 15.5 ft z 3 54 It 61 ft SEPTIC 0 4 67 f t 59 It TANK I B C A EXISTING DWELLING # 3 9 WATER LINE REGENCY DRIVE NOT TO SCALE C LE t5-2229.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Regency Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Arthur and Norma Erickson November 1, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 50+feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4/20/83 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: USGS topography maps You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 4.2 feet above the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is over 50 feet above groundwater table. t5-2229.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 L A T ION � S E*A G E PE RMIT NO. ! `I l L A>>G E el INSTA LLER'S NAME b ADDRESS `i BUILDER OR 0 NER -21�41e DATE'-i PERMIT ISSUED OAT E COMPLIANCE ISSUED �1� �� Megsv.�e ��eo k(• �� �, Rowe cv,eAle�es. i 17 ww 1t2e. ti�� c No.«O _ f O THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH �.......:............0 F..... `. ........................................... T7 Appl ration for 14spusal Works Tanutrurtiun rrrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal T System at: -- « . LocationddressSOt ^ or Lot No. ................«..«_ �1'L!/.IC1, :. . « � ._.._...-J........ ..................................................................................... ... Own.. Address . ./ Installer Address Type of Building Size Lot.L!01..._..G.... U Dwelling—No. of Bedrooms.................. .............Expansion Attic ( ) Garbage Grinder `04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtu =y Design Flow.................... S..................gallons per person per day. Total daily flow........................3�,,aQ. .....gallons. _ t! Septic Tank—Liquid capacitylCCOgallons Length............... Width................. Diameter................ Depth................ 14 Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area........_.........sq. ft. % �4 ` Seepage Pit No..........,......_.. iameter.......� ...... Depth below inlet._....&........ Total leaching area-. .sq. ft. Z Other Distribution box ( Dosi tank / �'ercolation Test Results Performed by. �C12,, .N.'�'t'....k4.'...Y�� S.. Date........... ,/«G/ ....... Test Pit No. 1.:.Zrc....minutes per inch Depth of Test Pit....._M...... Depth to ground water........................ Li Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ................................................................................•---.............------............--•--•-•---............................... 0 Description of Soil... . -•--•- . •--•...................•-.....•••.....................-•-•--.................•---•...._.. l(�1!S11.. l,1� :...... �Jt t...... ......................................................................... Z .....................•----------------......------.--------------------••- ......... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•-••--••--•--------------•-•--••--....---...............---••-•-•---............----•--------•----.....---•-•-•--------•-------...-----•---•--.........................--••••••---•....--•••---••••.... Agreement: The undersigned agrees to install the aforedescribed Indivi ewage Disposal System in accordance with the provisions of iITIS 5 of thy. State Sanitary Code—The u ersi d further agrees not to place the system in operation until a Certificate of Compliance has been is d by th boa of health. ed.. .... . .... Date Application Approved By_,. .. ....... ............` ,1�.. ..�.... ate Application Disapproved for he ollowing reasons:...........................................................................................................--- ..................................-....................................................................................................... ........................................................... Date « r PermitNo...................................................«.... Issued....----•---•--.......---...............•---............ Date �t THE COMMONWEALTH OF MASSACHUSETTS �/BOAR .OF HEALTHY' c..--�--- �QL ...................OF..... t\w..LJ .......................................... Applutttion for Disposal Works Tonstrurtiun Permit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ................__--. �::�N :.� � .....--.:��L..... :. i.. .....-----..--.------...............C- -:.....Viz:...........__.........._.... Location- ddress or Lot No. ....................... ..........L t Za CSo jJ--•-• ........................ ..-.......................... ................ �. Own Address -G� ------------------------ • .! •-•-•.......•-••-•---........................... .......••-•-•••--••••••••......••................•••••......••••••............................._.. Installer Address /� Type of Building Size Lot_. ! �...A-< ..'Sq.--iM U Dwelling—No. of Bedrooms..................S.....................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtu W Design Flow.................. .S..................gallons per person per day. Total daily flow......................... .....gallons. WSeptic Tank—Liquid capacity gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No............ ....... Width-.�...t-.-.-..."I". Total Length.................... Total leaching area.....yy.��_.��.........sq. ft. i Seepage Pit No........... ..._.._�iameter._.....r,.�....... Depth below inlet.......l!;>.'...... Total leaching area...1.r4. .sq. ft. z Other Distribution box ( Dosin tank ( ) ( �j I _ �:. Percolation Test Results Performed by.. A)C? 1�„ �_. ` 1`?:.....N . �1:) r-,.......... Date........... --���� g _...... Test Pit•ND. 1.__.T.....minutes per inch Depth of Test Pit._ 1 Degth to ground water..._.""'"'............ fz, Test Pit No. 2...........:....mii utes per inch Depth of Test Pit.................... Depth to ground water.................... ,a ........... ----------------------------------------------------------------•---.......................-------- ------------...............�A- '. Description of Soil... -.............••. ... ........ ......... U ��( ` ;:1►.-i1. �ti.��a' ......... :..::..ja.{......r, ....---•--•-•-•---.. ..........................•...-----:. ...._---•--......4 ............................................................. -- ......---_.....•----•................•.....-------•_..._/•--••----•---- ------.........._.................-•----........................................---------•--..... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•---•-•-•- -, --•---••-•. . ............................................................... __.....---......--••--•---...........------.......---..................--•--...... Agreement: The undersigned agr ,s" to";install the aforedescribed Individ age Disposal System in accordance with the provisions of TITLL )of-the State`Sanitary Code—.The undersi` gnfurther agrees not to place the system in operation until a Certificate of Compliance has been iss by the La of health. d.... .... . .............. .... ......../?. ... o• - . .... . ate Application Approved By1heollowing `, - �.f, .... ....... ...ate Application Disapproved f reasons:..................................•--- ------ ...................................................--- .....-•-•-----••...................•--•--...-•--•-......-•--•-----••--•-•-------------------......-•-----------------•-•........--•-- •I------------.._............-----•-•---- ---•---••••••-- �' Date PermitNo...................................................-.... Issued...................................................... - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... 01prtifiratr of Tompliana. THI� T�I�CEITIF ; dual Sewage Disposal System constructed ( r Repaired by...._. ../ ` -------------------....... . -------._. --- ---...•••-••..........................-•-------------......... .-------------------- - (---) -- +�7 Installer at....................... •-- .._.........L.•....r... ............---- --.......-------- --------.............---...---................----- .._......._... 4 has been installed in accordance with the provisions of TIT�3 _5;*f State Sanitary CZ in the -4..... application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE THAT THE SYSTEM WALL UNCTION SATISFACTORY. DATE..Q.•f ........................................................ Inspector . •.. ... -•---�-••-.._._.. ---•--.......... THE COMMONWEALTH OF MASSACHUSETTS ��// BOARD OF HEALTH �( -.2 T/r ...........................................OF..................................................................................... 4/e0 No......................... FFx........................ 3�is us Tanstrurtiun Permit Permissionis hereby granted....... •...............•--•-----,.. •. •.--............_..----..._._......-••••--••-•••.........................................---- to Construct 4 'r ( ) In ividual Se vt Disposal System atNo...__. �' '._.�. .... ............... --- --...----...... street••---•--..•----•--•• --�-1 •-----. .��!.['�. .... as shown on the application fo{Disp sal Works Construction Permit No...............f _. t '� .... ......................................... .../Health DATE...................¢` ' ....... FORM C-1255 CITY& TOWN FORMS, INC.369-9708 �.. y I $I�G�� FAMILY - :5 6E02ooM wo G,�RBAGE C7211•ID6R. A V,%., FtoW jL I►0X 3 = a30G.po, Wtt�.L SEPTIG�-rA►uK a a3ox15�% =�495G.Pa - - - -, -- ,•{ -. - ---: ...� . . USE- l000 GAL: _ , ; ; ; f. .} i �.� t . , • ' ; n2 uSE taoO (-SAL. �p`1N Oi,ygs , 1. f- o15PasAL PIT •� �{. F �., f • ' S I p�v+lA1.L _AREI► .�; 15o S.R ALAW .150 $•� x i'�.•5 R 3?5 G.PO„ '.. u JONEs Nil�• i '� �.'y'� c c BOTTO/K AREA f . l� �F• .r.. .i %-f No. 25100 j.5. oTAL. D6.SIC•N ,. O DAILY FLOW � 330 C.P. ^ ...� j J, �... � . t i 111W VAIN oR.L1=5s J 3/ . G . .;', •' , 'PE�2GoLATIoN RATE - .�. ., i � "• ' .I � � ! ., � •�_ � 'IG�Z 9�, ..'k. �.� .� '. �.,��F.-� fir x_ • � Ao FHCHA b SAXTER \! No,'24DQ aM ca. . _ 1b�•f►r�� B;: `It 1 HD SUS t , .41 t• f. •' i i W �� • .ja•,p Ara Jr q1it V Gat. .,. • ��Z.�; , J 1 odo I NY, 6oK •`LI: 'T�N.>l�4 ." { i iNV INV. �. . i f 4.4 } + pL0 r 'PLA1J CERTIFIG t.O Z AZ I o N y f,QPs7ts;�'� WAtE' IZ. « P`Lp;1•1 REF62fs� Gfc: p,�tm�s cv F�S�.SNo v�1N ' '.v CE RTIFY NE,RSOW GoMPL`(5 1n11TN'THf� Sl�fst-IN Es ,Lo7"'_3 -` y ' Au0 sr=Te4cK R6QuItz>:M6NY5 ot=-t1f1Er •�; G./Ltf7 .?�� ' ` LOGp.T D MAN TN6 GLoo PLAIN f , . t PAT Z BAkTE1Ze IJ�{E INC•� ' • • R.EG 1 y�6.Q.6ti'LAu�S u�Y�aYo2'S ?NIS PL&W 1`5 W&T oao F E-f5 614ou0 osTEQ.VILt.E • µASS. 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