HomeMy WebLinkAbout0325 REGENCY DRIVE - Health 5,
�.°�, �� e ency "DrivePa
064�036 '' Marstons Mills
"a
No: ` _ / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpliLation for ]Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Addressor Lot No.3a5 Ac—G-9,v,.4 Dk r kM Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel O(p Q 3 'S KAA_ fLt
Installer's Name,Address,and Tel.No.508—4'71--281 I' Designer's Name,Address,and Tel.No.
4 APewt'pC peuS LA_C- M1A
I5
Type of Building: ��� a 11 q&q
Dwelling No.of Bedrooms J"'l Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) AA gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
iPs� �-l3oX. — t U 5�14-�- �-rt c
e D icl �t6� K
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of 119uk
Si d Date 1 a - t - t q-
Application Approved by Date /d
Application Disapproved b Date
for the following reasons
Permit No.e 0 j q Date Issued (� (n (?.,i
1
No. f Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
_ �4plication for MisposaY 6pstem.Construction Vermit
s
Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No.3a S Ac-Gavof 14M Owner's Name,Address,and Tel.No.
M� l.pGtL)
Assessor's Map/Parcel Q(p�{ 3(p M A4RS rb A4 C LA.--
In taller's Name,Address,and Tel.No. _7- ?7' Designer's Name,Address,and Tel.No.
APEwinE E PAJSMg L-L-C_ Q1A
t 53 S-7- 4_ 4S9F5E;**
Type of Building:
Dwelling No.of Bedrooms 1Y� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided /� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
IV �j _rA
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until Certificate of s
t Compliance has been issued by this Board of He
Sig d Date
r. Application Approved by —"� Date
Application Disapproved Date `
I for the following reasons
Permit No.Z 1 q Date Issued I
----------------------------------------------------------------------------- =--------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CCERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( )
Abandoned( )by 064-pe mG & T)-r else'
at.3IS �(r���,�� � 1ul AD-C TDOC Al/4k-S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No y` (�7 7 dated 1410
Installer O-A0G"kjl t)G C^?..1 f$ ' U-C.. Designer VIA
#bedrooms AA 1 Approved design flow /� �� r� � gpd
The issuance of this permit shall not be construed as a guarantee that the system willifimction as designed. J r/l` \ -�,
Date i' /`�... il. "t! Inspector ,{,/ 1, /. '3/� - ,� �.•' !f J
_ _________ ___________________________-_______-__----------_--_-.._____-____.___-____-_._.____.______._____..______._____--------------------------
No. a01 ('f_ Fee 00 �a
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Vermit
Permission is hereby granted to Construct( ) Repair(k Upgrade( ) Abandon( )
System located at 3a� ��G�JC' D� 1✓I�RS'tsJ s -i(1.��
i
i
0
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. �—
Date r z (abo i y Approved by
r '
Commonwealth,of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yy 325 Regency Dr.
Property address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityrrown State Zip Code Date of Inspection
o-�
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 A. General Information
filling out forms 'L �0pnunngq1'�
on the computer, (� moo` ���OF MASS
use only the tab
1. Inspector:key to move your off: '•.OyG
cursor-do not James D.Sears JA M E S :m
use the return Name of Inspector
key.
CapewideEnterprises,LLC ' *;
Company Name !F n... ....•G�
�t-�-. Q
153 Commercial,Street_
Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
Sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
0 Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
12-15-14
spectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and_the system owner shall.submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
114 bsi I
t5ins•3113 Title 5 OtfiaW4on Form:Subsurtaoe Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owners Name
information is required for every Marstons Mills MA 02632 12-15-14
page. CityRown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 bal.-Tank D Box and Pit.
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3113 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup_or break out or high static,water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
0 broken pipe(s)are replaced ❑ Y ❑ N 8 ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 3 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owners Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Citylrown State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method.used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure Criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other-.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due:to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in aos=W is less than 6"below invert or available volume is less
than day flow ,'/T
t5ins•3113 ride 5 Official linpec Lion Form:subsurface Sewage Disposal system•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner ownets Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOTdue 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
tributarysupply.to a surface water
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custodyy must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
f Large Systems: To be considered a large system the system must serve a facility with a
1 g Y r9 Y Y dy
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3M 3 Title 5 Offi ial inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5))
D. System Information
Residential Flow conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
lugTitle 5 official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner owners Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and Pit.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) El Yes ®. No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2013-35,000Gals
2014-10,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-:sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owners Name
information is required for every Marstons Mills MA 02632 12-15-14
page. City/Tcwn State Zip Code Date of Inspection
D. System Information (cont.)
La
st date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumping every two years
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form-
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Tank and Pit 1984 Permit#84-1004/12-2012 New D Box
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:- 3411
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4"PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 20"feet
Material of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
1"
t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Tape-PlanSludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level. Tank at 20"below grade w/inlet cover at grade. outlet ever at 10" in
and outlet tee's. No sign of leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
El concrete 0 metal El fiberglass R polyethylene other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 325 Regency Dr.
Property Address
Mildred L.Logue Trust.
Owner Owner's Name
information is Marstons Mills MA 02632 12-15-14
required for every
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
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 tract o ns i n:
co
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16"-2' Below Grade w/cover at 4". Box is new 12-2012 w/one Line out.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No'
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 TiUe 5 Offidal Inspection Forth:Subsurface Sewage Disposal System-Page 12 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r< 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
z leaching pits number: 1
❑ 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.):
Leaching is a 1000 Gal. Precast pit.w/2 stone. Pit at 5 below grade w/cover at 4". 20"
water in pit w/stain line at 2 off Bottom of pit. No sign of over loading or solid carry over.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3h3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
UTTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Dr. T
Property Address
Mildred L.Logue Trust
Owner Owners Name
information is
required for every Marstons Mills MA 02632 12-15-14
pays, City/Town State Zip Cade Date of Inspection
D. System information (coat.)
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
,A'�"` �aJ
(34 _ ;3
�l/_� R FAR
O>EeK
0 3
i
m•3/13 US 5 OW9 kdPXf1W FO"M&t>swlbM Sewage Oisposai System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells Nv
Estimated depth toFigh ground water. 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date 4
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:
T.H.on File at B.O.H. 3-13-84. No G.W.at 12'. Bottom of pit at 11'below grade. Bettom of Pit at 1'+
above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsufaos Sewage Disposal System•Page 16 of 17
s '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 325 Regency Dr.
Property Address
Mildred L.Logue Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02632 12-15-14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated
depth to high groundwater
P 9
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3M 3 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
obq-08(jp
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name 07)
information is
required for every Marstons Mills MA 02648 6/22/2018 MI.
page. City/Town State Zip Code Date of Inspection }
h•�
r�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information C
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Ronald Burlingame
use the return
key. Name of Inspector
Company Name
58 Oak Street
Company Address
West Barnstable MA 02601
Citylrown State Zip Code
508-776-8544 S14124
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
/
! 6/22/2018
In 'ector's Signature 10
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 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.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System has had very little use. New D-Box was installed in 2014 & house has been vacant for years.
System still looks new. New pvc pipes from tank to D-Box to leach pit installed in 2014..
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
I ❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form I
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I
°wM ,0 325 Regency Drive
Property Address
Dean Stanley
Owner Owners Name
information is required for every Marstons Mills MA 02648 6/22/2018
page, Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 325 Regency Drive
Property Address
Dean Stanley
Owner Owne's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
i
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to.or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
4
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
'® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 G.P.D.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Septic Tank, D-Box-5 H.C. Infiltrators
Number of current residents: None
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
in
formation in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
No water in house. House has been empty.
Sump pump? ❑ Yes ® No
Last date of occupancy: N/A
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page, Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank 1984/D-Box new 2014/ Leach pit 1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 15"deep to top
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: Covers to grade
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
0"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
0"
Distance from bottom of scum to bottom of outlet tee or baffle
0"
How were dimensions determined? Clear tube-tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
System still looks new. Tees are in great shape, water levels are right, no leakage from tank or D-
Box.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box if resent must be opened) locate on site plan):
( P p ) ( p )
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.):
D-Box at working level, still looks new.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 (6x6 w/stone)
❑ 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.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 325 Regency Drive
9 Y
Property
p rty Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
hR.�xST
3a 6
3 38 / IOU
�1-�vk Coca �-
1
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12"feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: B.O.H. 1984
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:
From plans at B.O.H.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM a''a 325 Regency Drive
Property Address
Dean Stanley
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6/22/2018
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
yea RS '� �,,,...- ✓J, � ` �� ��_
CAT ION SEWAGE PERMIT NO.
k � `
VILLAGE
I,NSTA >LLER'S�_ NAME i ADDRESS
.�1�®I /�/G-✓motet/
B U I L D E R OR OWNER .
DATE PERMIT ISSUED
D A T E COMPLIANCE ISSUED
A-eA A-
�l
tv
t
No........ A FEB......... .. ........
THE COMMONWEALTH'OF MASSACHUSETTS
l BOARD OF HEALTH
.......................................OF..........................................................................................
Appliration for Disposal Works Tonstrurtiun rumit
Application is hereby made for a Permit to Construct 04 or Repair ( ) an Individual Sewage Disposal
S stem a
' u .... 1 �' ......... ........................................ ot ---•--- .------- . .-.-
o
cLocat Address o
.. � .........
Owner Address
.............................. ...............� ..-- --••-•............••............. -•-------•---••--••-----•-•------..........----
Ynstaller Address
U Type of Build g Size Lot.. j. ..��q. feet
Dwelling—No. of Bedrooms.._____.___..........................Expansion Attic 1 Garbage Grinder
'_l Other—T e of Building No. of persons__________________________ Showers — Cafeteria
Otherfixtures --------------------------------------------------------•-----•--•--------------•--------------•-••-•--•-•--•.
W Design Flow....................e -------gallons per person per day. Total daily flow............... ..... ....___galIons.
W Septic Tank—Liquid capacit 0,
W. . allons 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 W
Percolation Test Results, Performed by.......................................................................... Date.---------- ....
a
Test Pit No. 1. _----minutes per inch Depth of Test Pit.................... Depth to ground water,
Gc, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil. (�1 �,C�....5C ,!• J ��.� �........._..
x
W ---------------------------------------------------•-----------•----•------•---------------••-•-----•--•-•--•----•------------•--------•------------•-••-----•••--•---------•-•----•---•-••----•-------
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
•-•------------------------•--•--....-•---...-----•----------------------------------...----•-•--•---------•----------........------------------------•-----.........------------------..__........••-•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L IME 5 of the State Sanitary Code—The undersigned furth a es not to place the system in
operation until a Certificate of Compliance has bee ssued by t and ealth.
Signed -•-- . --•---• ------.
at
ApplicationApproved By........................................ .-•......'-- ••. . •• •. --------••••••--- ........................................
Date
Application Disapproved for the following reaso :.. __
--------- ----•--•------...-•--••---••-•----••........-•----------------•-•---•. -
..................•-•--••---------.....•--...._.....---•-------•-•------•..._ ----...-•----.------.•-----......--••••............-----•............-•----..... ............_.
Date
PermitNo.......................................... ------------ Issued_.......................................................
Date
f
No................_..: Fins...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................................----.....OF.........................................................................................
Appliration for Disposal Works Tonstr ion "truth
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...-•---•----•----.....-•................................•-•--•-----..........------•-•........... ........-••--------------•--•-•-•-•--------...---•----------------....--••------------......----••
Location-Address or Lot No.
......................__........................................................................ ..........---------.........•..._......-...... ...............................................
w Owner Address
a ............................ ��/- L�f, �sc -
Installer Address
Type of Buildin Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------•----------•---.......---•--•-•--...•--
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.................... TotaLleaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) `"
Percolation Test Results Performed by....................................................... = Date.
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 •--•---••--•------------•---•-------•••---•••---....----•••-------•--•-••••-••-----------------••---......
----------------
•-------
--.------------------------
0 Description of Soil.......................................................................................................................................................................
x
c.>
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 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 by the board of health.
Signed ........................................
^ Date
Application Approved By.............................. .... =' �' --------•-------•- ........................................
Date
Application Disapproved for the following reasonY... ...........'-A7............••---•----•-----•-•-•--•--••--••------------•-•--•-••-•----•---•.............•--
.y/ r
.....................................................................•••-•...•----�:,;:: c'---......•-•-••-•--•-•---••---•----•--•-••-•-••--••......--•------
f ..
Permit No..........................................1 Issued.---.......--•-------------._.._...-•----.Dau--•---
Y•_..._......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................I.........O F..............................................................I......................
Trr#ifirtttr of Toutph anrr,•
THIS IS TO CERTIFY, ThaQthIndivid ewage Disposal System constructed ( )j or Repairedby......... ...}:-.. 1�:r -z --.......•--......-•--•---•---------------•---.................••-------•--•----
�r" Installer 1�
has been installed in accordance with the.provisions of TITIF 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated.................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
0
DATE...............................
r�=1 ---------------- Inspector.................Q-,.4.............................................. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF......................_........._...................................................
No........................ FEE=f....................
Disposal Works w4rudm rrnti�
Permission is hereby granted...................................... . l l``' �� {' =`-
to Construct ( ) or R �n pair ( ) an Individual' Se�
`ge Disposal System � y
at No....................k I;:. . �1 a^
1
Street
as shown on the application for Disposal Works Construction Permitr ___________________ Dated..........................................
..........vtrt ..._..--..----------------------------------•-------.....-----................._
DATE........... . --=`• ...
... Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
No------------------------ FIms..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................... ......................OF_.....................................----.....-----------..............---.............
Appliratiou for Disposal Works Tonstrnrtiun rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__.............................................................................. ........._...........•••-•-----••--••••-••--•-•••-•-'•-•--••-•---••-•......-••-•.......-•-••-•----
Location-Address or Lot No.
............... •. ..... ....... ._......._... .........
Owner Address
W
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
a~ Other—T e of Building ............................ No. of ersons............................ Showers —
Other—Type g p ( ) Cafeteria ( )
dOther fixtures ----------------------------------------'---------•-------•---••--...----------------------------'----'-•"•-•'---••------'--......---'-'-------'---
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 ( )
1.4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--------................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---................---.
C4 --------•----'----------'---------------'-------------------•---....-----''••......-----•'-'-...•-'-'•......-'-'-'-'---•--•--••.............................
0 Description of Soil........................................................................................................................................................................
x
U -----•-------'-•-'............."•'•-'-•-'••-'---•--•-'....----•-.......-'-'-------••......-••--'•••-'•-••"---------------'---••--••---•-'-'--•-•'•----'----'-•'-••------....-•'-'•......----"---''---
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 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..................................................................................... ................................
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:----'•--------•------------------------------------------------------------------------------------•'.._.._.....
--.......-•------------------------------------------------------•--------------•--------..._...-•------•---------------'------------------------•---------------------------------------------.._...._.
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Intifirate of Tnmlilianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at......................................................................................................................................................................................................
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 SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................•--.......-----•--•-•-•----•-••-•--•-'--......-•••...•----...... Inspector....................................................................................
........•.•.••.•.•.••••••.•so....•.•.....••off•...•..•..Q...................................................................�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F..........---........................................................................
No......................... FEE........................
Disposal Works Tnnstrnrtuan rrmit
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo.........................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
....................•-------------------'----•--'---------------'----..-----•-----------•----------•--•-
Board of Health
DATE.
FORM 1255 A. M. SULKIN, INC., BOSTON
I_
No................... -• - FsE...................._....._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... ..................OF.......................................--------------------......._.........--------------
Appliration for Disposal Works Tonutrnr#ion rrmit
Application is hereby made for a Permit to Construct ( . ) or Repair ( ) an Individual Sewage Disposal
System at:
................_........_...................................................................... --••••-•••-------•••--•••..._........--•••--•-•--...-•----•-••-•-•-•--•-•-......_.....--•---•--•-•
Location-Address or Lot No.
-------•.................•.....................Owner
ner Add....•-------••-•.......................... •••••••-••--------........................•••• es.s...................................._••••.
ress
W
. •••a •.............................................Instaaller ll.er.._.......•--••••••.........._......•.... --•---.....-••---......................•.....Address es.s.•••---._.........•....................._..
d Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
............... No. of ersons.....__..................... Showers — Cafeteria pa., Other—Type of Building _____________ p ( ) ( )
Q' Other fixtures ..................•--•---------- ...
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-----..................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Q+' --------------------•---......-------•---------------------.........------------•................--•..............................................
.----
••••--
0 Description of Soil........................................................................................................................................................................
x
U ----••---•-••---••-----•--•------••-••---------------------------•-----------------.............•-•.....•--------------------•-------•-------•------•--•--•--•--•••---•----•-•-•--•--••--------•--••----
w
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V 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 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...................................................................................... ..........................-....
Date
ApplicationApproved By.................................................................................................. •••-•..................................
Date
Application Disapproved for the following reasons:..............................................................................................................
..........................•••.......----...........--••------...-•••.......------•---••••--•-------....•.---------------------•------------------------------•---•-•-------•----------------•--••-.-•••-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(9rdifiratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------------------------•-----------.-----------.----..--------.------.--•- ---------------------------•--•-•----------------------•----------.---------------•----•----------------
Installer
at......................................................................................................................................................................................................
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 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................I........................OF.....................................................................................
No.............•........... FEE........................
Disposal Works %ons#rudion rrmit
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo........................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
...................•...--•-•---------------------------------------------...-----....----......•--••----
Board of Health
DATE................................................................................
FORIVI 1255 A. M. SULKIN. INC., BOSTON
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5,5
Log'Number,: Bottle # D137L Date: 1.0/17/84
BARNSTABLE COUNTY HEALTH DEPARTMENT,
SUPERIOR COURT HOUSE
BARNSTABLE, MASSACHUSETTS 02630
o •
�fnso,
DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2511
EXT. 331
Client: Ken Stewart Collector: Edward "P. •Meehan
Mailing Address: 1 Heather Hill Rd. Affiliation: Meehan Well Drilling
Sandwich, MA 02563 Time & Date of , t . , .
Collection: 1 10/15184.-10:15 a.m.
Telephone: 428-5762 Type of Supply: well water
Sample Location: lot, 10-325 Regpnry Dr- Well Depth: 81 '
Marstnns Mills Date of Analysis: 10/15184
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS
Total Coliform Bacteria/100 ml 0
H
Conductivity (micromhos/cm) 500.0
Y f
Iron m) 0.3.
Nitrate-Nitrogen ( m) 45 . 10.0
Sodium m) 20.0
I.- Water sample meets the recommended limits for drinking of all' above tested parameters.
II. Based only on results of the parameters tested for this sample, the water is
suitable for drinking but may present the problems checked below:
A. xx•, Water sample has higher than average levels of Nitrate. Future monitoring is
recommended (2-3 times' per year) to establish any upward -trends.
r
B. The' low pH of the water may shorten the useful life of the house's plumbing.
C. Water may present aesthetic problems (taste, odor, staining) due to
D. xx ' Water sample has highJevels of sodium. -Persons -on low sodium- diets -should
consult -their- doctor. {
III. Due to one or more of the reasons checked below, this water sample is unfit for
human consumption: A. High Bacteria B. High Nitrates
REMARKS: t
CC:
CC: Meehan Well Drilling
Barnstable Board of Health Laborato y Director
7/17/84
Explanation of Test Results
Total Coliform Bacteria ,
Coliform bacteria are an indicator of the sanitary quality of a water-supply. Waterrsupplies may become `
contaminated*from malfunctioning septic-systems,cesspools and surface runoff. A total coliform count,.of zero
indicates that your water supply is safe and-approved for human consumption.. A total coliform count of greater
than zero is most often,the result of accidental contamination of the sample bottle through improper sampling
methods. For.this reason, it would be advisable to retest any well water that is not approved.
pH is the measure of acidity or alkalinity of the water. On the pH scale, the number 7 is neutral, less than 7
is acidic and more than 7.is alkaline. The pH of water on Cape.Cod tends,to be acidicrinithe.ran ge of 5.0 to 6.5
Conductivity
Conductivity is a measure of the dissolved salts.in solution. Amounts in excess of 500 micromhos'-m are
generally considered unacceptable and may have a laxative effect upon users.
iron
The presence of iron in water in concentration of .3 ppm or greater may: give the water a.bittersweet
astringent taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry
and porcelain. The average concentration of iron in Cape Cod's water is,.2.- .6 ppm. Although the presence of
iron in water may cause the problems listed above,-it is not considered deleterious to health. Iron may. be
_ removed bv'use of an iron removal system..
r' . !,f 7 y-3 ,
Nitrate-nitro en `''.
3
The j%lassachusetts Drinking Water Regulations.have seta maximum contaminant level for nitrates at.10
ppm. Excessive concentrations may cause methemoglobinemii (an infant disease).and have been'suggested to -
form potentially earcinogenic nitrosamines-.Contamination-sourcesAnclude'fertilizers, cesspools and..i.ndustrial:
wastes.. {
Copper
We to the,acidic'naturraf the water on Cape Cad, capper tends to leach-from pipes. This normally.does ,,
not present a health hazard; however, concentrations in excess of 1,0 ppm may,cause a metallic taste and/or a
bluish green stain on porcelain fixtures.' .
Sodium `
A concentration of sodium over 20 ppm is only of concern to people who are on+a low sodium diet:If the '
water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source
of drink ng water or contact their doctor to determine if consuming the-water is advisable. Concentrations
exceeding 50 ppm indicate that there may be ocean water or road salt runoff water vetting into the well.
Department of Environmental Management/Division of Water Resources
WAFER WELL COMPLETION REPORT
WELL LOCATION j�
Address Lof to .3a.5- .n'eC3ehr' 4 D& '
City/Town Mci rs IzIns rr 1 II S
G.S.Quadrangle Map
Grid Location
Owner KP rl,
Address $ ���i,(YGPt�Yr1!'
WELL USE CONSOLIDATED WELL
Domestic 0 Public ❑ Industrial ❑
Type of Water-bearing Rock
Other //l� Water-bearing Zones
Method Drilled
(7U aer 1) From To
r 2) From To
Date Drilled /0 '�� 3) From To
4) From To
CASING Al rr Depth to Bedrock
t
Length c':h) Diameter
Type j;,1u s-/f( UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing'Materials
Feet below land surface �0-3 1 Sand: fine❑ medium Q coarse El'
Date measured 94 Gravel: fine❑ medium❑ coarse❑
Screen:
GRAVEL PACK WELL 1
Slot* /0 length from—to—
Yes 0 No
Split Screen(or 2nd screen)
WATER QUALITY TESTS MADE Slot# length from to
Chemical ❑!r Bioloqical ❑ Depth To Bedrock
PUMP TEST �f
Drawdown feet after pumping days � hours at 20 GPM.
How measured qa o'r r''A 10 Recovery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
0
o'
m
r DRILLER y
�ll V i+J Firm ian ai( ,110r,16A G 0
n Address f-DeX rY-00 V \
City %ores ric,ra re, rn va b 44
n r� Registration No.
operator's Signature
Please print firmly
BOARD OF, HEALTH COPY 5M-2 84-176171