HomeMy WebLinkAbout0454 REGENCY DRIVE - Health Pr
454 REGENCY DRIVE, MARSTONS MILLS
A=064-051
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f `� Commonwealth of Massachusetts /
,0� Title 5 Official Inspection Form
p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr ,
Property Address
Rhonda Snow
Owner Owner's Name 'J
information is 1913
t Marsons MillsMA 02648 5- -
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information ic38sq
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above; the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes,
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
5-13-19
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� wa
ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
s � Commonwealth of Massachusetts
r� Title 5 official Inspection Form
!xi o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
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 El ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El ❑ 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:
t5ins .doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
PP 9 P Y 9
1
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'F�'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
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 11 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
01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
tl jo;'
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator.of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® 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?
® ❑ Wasthe 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
rol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
2019
Last date of occupancy: Date
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
'
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): 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: 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:
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
y
r " Commonwealth of Massachusetts
l,, Title 5 Official Inspection Form
M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Tank and pit 1980's with leach chambers added in 1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"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.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
,w. Title 5 Official Inspection Form
I'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 6"feet
Material of construction:
concrete metal fiberglass
® ❑ ❑ e glass El polyethylene El other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
1„
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert evidence of leakage, etc.
q 9 :)
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
r� 4. ,, Title 5 Official Inspection Form
i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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.):
8. 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c Commonwealth of Massachusetts
fia y Title 5 Official Inspection Form
h. �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
z: 454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
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):
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.):
There are two d-boxes and both are in good condition with water at working level and no sign of back-
up from field.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r W ,r,
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is Marstons Mills MA 02648 5-13-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* 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:
® leaching pits number: 1-1000 gal
® leaching chambers number: 3-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
�w Title 5 Official Inspection Form
C,4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i",'n'
-,• V
=1: 454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with no visible stain lines. Leach pit was
empty at inspection.
12. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I oI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System information (cont.)
13. 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
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•� ` ,� Commonwealth of Massachusetts
Title 5 Official Inspection Form
I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r fY�
T, ?' 454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. 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: 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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
4. 3< Title 5 Official Inspection Form
%I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 Regency Dr
Property Address
Rhonda Snow
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-13-19
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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No. Fee . S 0 _0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYicatiou for Digpoear 6pgtem Conttructiott permit
Application for a Permit to Construct( )Repair(X)§Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 454 Regency Drive Owner's Name,Address and Tel.No. 4 2 8—7 0 3 8
Marstons Mills,Mass. Clair Lane
Assessor'sMap/Parcel 454 Regency Drive Marstons Mills
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 H Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 H
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling xx No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building RES No.of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Existing 1 000 Type of S.A.S. Existing 1 000 gallon pi
Description of Soil Loamy sand to medium sand.
Nature of Repairs or Alterations(Answer when applicable) 3— 500 gallon chambers packed
in 3 ' of 11" stone with a 2" pea stone cap.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by this d c Health.
Signed ! Date 1 2/2 4/9 7
Application Approved by Date
Application Disapproved for the f0yowing reasons
Permit No. Date Issued
---------------- - -
r
-----
TOWNOF.BARNSTABLE
LOCATION y3y e N Y ' • SEWAGE # y
G ASSESSOR'S MAP &LOT-IL°l-OJS/
......
t,II;LAGE
:INSTALLER'S NAME&PHONE N0.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)
�LO(dC�/+MI3 R5 (size) OU. /)G
N —OF BEDROOMS_��_
: UIDER OR OWNER
ERMTT DATE: 1 ^ 1 — 4 6 COMPLIANCE DATE:
P.
<;S.epaiation Distance Between the:
Feet
jvlaaimum Adjusted Groundwater Table.and Bottom of Leaching Facility
:'Pvate Water Supply Well and Leaching Facility (If any wells exist Feet
:.;gri;site or within 200 feet of leaching facility)
Wetland and Leaching Facility(If any wetlands exist Feet
:< :within 300 feet of leaching facility)
y.. ,
'Famished by
f
4 M
No. 0 U Fee .$ 50 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Z[pplica.tiou for ]Di5pogar *p5tem Cori.5tructiou Permit
Application for a Permit to Construct( )Repair(X,'�Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 454 Regency Drive Owner's Name,Address and Tel.No. 4 2 8—7 0 3 8
Marstons Mills,Mass. Clair Lane
Assessor'sMap/Parcel 454 Regency Drive Marstons Mills
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling xxNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building RES No.of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Existing 1000 Type of S.A.S. Existing 1000 gallon pi
Description of Soil Loamy sand to medium sand.
Nature of Repairs or Alterations(Answer when applicable) 3— 500 gallon chambers packed
in 3-', of 1 1" stone with a 2" pea stone cap.
Date last inspected:
i
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 Co e and not to place the system in operation until a Certifi-
cate of Compliance has been issu by this o d o Health.
Signed / Date 12/2 4/9 7
Application Approved by Date
Application Disapproved for the torlowing reasons
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(XX)Upgraded( )
Abandoned( )by-J.P.Macomber & Son Inc.
at 454 Regency Drive Marstons Mills,Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc.
The issuance of this permit shall not be construed as a guarantee that the system w i�l-func on as designed.
Date t / 77 Inspector-
----------------------------------------
! —
No. Fee '
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwigpooal *p.5tem Cougtructiou Permit
Permission is hereby granted to Construct( )Repair�X )Upgrade( Abandon( )
Systemlocatedat 454 Regency Drive Marstons Mills,Mass.
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: Z — / Approved by
f
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
1,Joseph P.Macomber jr. , hereby certify that the application for disposal works
construction permit signed by me dated 12/2 4/9 7 , concerning the
property located at 454 . Regency Drive Marstons Mills meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
•� There are no variances requested or needed.
•J If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the
proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 45 ,
B)Observed Groundwater Table Elevation(according to Health Division well map) 9 r
SIGNED : DATE: 1 2/2 4/9 7
LICENS D SEPTIC SYSTEM INSTALLER IN TH TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
q:health folder:cert
7 coo C
19��
wo
V Vie.
. ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF........ -----------------------
2XVVIlratiou for Ui_qpasal Warks Tonstrurtivit rprmit
Application is hereby made for a Permit to Construct Repair an Individual Sewage Disposal
s
tem at:
o ati ca i 0
.......................... ..................................................................................................
RInstaller
con Qfflress . L
ot No.
Owner Address
............................ --- Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms......_...3...........................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons._...._...__................ Showers Cafeteria ( )
04 Other fixtures ...................................................................................................
.< ........................
................. ...........
W Design Flow........................5.5...........gallons per person per day. Total daily flow.....-*...........3'i�..........gallons.
WSeptic Tank—Liquid capacity/M...gallons Length................ Width.........._...__ Diameter..._............ Depth................
Disposal Trench—No..................... Width..................._ Total Length.................... Total leaching area....................sq. ft.
> Seepage Pit No............ ameter..........4.... Depth below inlet.......6......... Total leaching area....2.4V..sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.VAgvV_,,±A.yA.....A.-.1a9ft.. Date....1;?d.n.jas
Test Pit No. 1_...' '.....minutes per inch Depth of Test Pit.........172. Depth to ground water....2!!.-�........
Test Pit No. 2................minutes per inch Depth of Test Pit................._.. Depth to ground water.........................
04 ..............................................................................................................................................................
0 Description of Soil.......................................................................................................................................................................
W .t>......ma IVM...........15S?A1dt>....................................................................................
---------------".......................................
. ......................................................................................................................................................................................................
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 TI LE 5 of the State Sanitary C, e he undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha n the board of h
...............................igne ........... . .......... S;
.. .. .................................................................................... -----/ --,!.......Application Approve --------------
iDate
Application Disapproved ollo ing reasons:................................................................................................................
................................................ .......................................................I...............................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
s
No................_....... .;. FEs....:..d...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I_I OF. i
Apli iratiun for Diupuiittl Workii Tonstrur#inn thrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
L ' .. - . r atio
...........-- .. .............•••....... .....-- ----. ••.-- Lot No.
..............................................
Owner ..+ Address
. `....
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............3..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ...:.............................
d --- --- -------------•--------
W Design Flow..........................
.......................T%. ...........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.
_ Diameter..........-�-'-�-.... Depth below inlet................ Total leaching area... =C.._sq. ft.
Seepage Pit No------------;;;Z Other Distribution bo Dosing tank
Percolation Test Results Performed �................................... ..,
--------=-... Date........................................
aTest 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........................
M ••••-•-••-••---•-•--•---•---•-•••.................•--------.........--•-----•--••••.........._..----.........................................................
0 Description of Soil........................................................................................................................................................................
, + , .....................li
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 Co e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has i s y the,board of,he)A.
igna ........... .. !......!! - ---............................•-----............._ ...........
Application Approved • -•--•-•. ----••-••-••....._.. y
} Date
Application Disapproved for h` f ollow ng reasons:-----•---------------------•--•----•----•---•---------...-----•------------•---•-------......---..............•.
---•--•-----••••••-•----•-----•-•----•-•-•••-•-•• ---.....................•----------......••-----•--•-•..--•-•-••-----------•-•--•----------•-••--••••-•-•••---•-------..-----••-••---•-•-----
Date
PermitNo.....................•---•-------------•.........._•.._. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
................. ..��..'................OF.........:? .:.`...-..h'/.`.!..1'. :5I- :.'................................
CIrrfifiratr of Toutphatt r
- " S GnERTIFY, That the vidu�I ewage Dis -•al System constructed ( ) or Repaired ( )
-• ---•• -- ..... ..... ......... ---- .....: .?+ �...... ---.....----------•--•--•-----•--•-•-----.........---.....-••--•----•--•-•--.....
jInstaller
1' -•-•----- ---•••----- ---- �✓—
h.. en instal ed in accordance wi i the rovisions of TIT.4F�5 o�The State Sanitary Code as described in the
application for Disposal Works, nstrp tion Permit No.__* .................................... date -.. ........................................
THE ISS NC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED GUARANTEE THAT THE
SYSTEIA�I �U N SATISFACTORY.
DATE..... ......... ........................................ Inspector............ ......................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
V L/ /�(� + t 1 O F. .. .....ti...L.!...!....... .r...-:::......................... F
No. r...... FEE J`....................
13i1141oua ur on#rudio rust -�--�
Permission is he eby grante •-•-• -- ..........r-. .....--•••-•-------..ls:-4,
- ........... ............................................
to Construct ( or Repai ) divid Sewage Dispystem
at 'No.--•................... •----- •--•---••--.•---- . •------•-------------------------------..............
tree
as shown on the application for Disposal Works C nstr ction Permit No..................... D . ..........................................
.............................................. ------------•-••--•--•-•----.....-••---...----•.....•..--
l •--- oar Heath
DATE.........J71— ..........•..............•----_.....
^•^e'•' FOR%(`1255 A. M. SULKIN, INC., BOSTON
Massachusetts Water Resources Commission/Division of Water Resources
WATER WELL COMPLETION` REPORT
WELL LOCATION
Address �A� �S C'_-� �ri�� '
City/Town �4 i/L5 s I 1 I _S 5
3
G.S.Quadrangle Map
ok-
Grid Location
X
Owner
Address 4+. afio?O e
WELL USE CONSOLIDATED WELL
Domestic Public ❑ Industrial ❑
Type of Water-bearing Rock
Other
Water-bearing Zones
METHOD DRILLED 1) From To
Rotary(type) u Cable❑ I 2) From To
Other 3) From To
4) From To
CASING �� Depth to Bedrock
Length w Diameter
Type '�'i- V t- UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surface 60 Sand: fine❑ medium❑ coarse
Date measured 13 Gravel: fine❑ medium❑ coarse❑
Screen:
GRAVEL PACK WELL g / !r E to�•Slot# `d length � from
Yes ❑ No
Split Screen(or 2nd screen)
WATER QUALITY TESTS M E Slot lenqth from to
Chemical ❑ Biological Depth To Bedrock
PUMP TEST
Drawdown feet after pumping days/hours at /0 GPM.
How measured Recovery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
Co. rtse i nd S 7S �
DRILLER h
Firm �1-�102D W��l Jrt
Address 1 93/u� ncOG�C %?c4— `
CityZe l/r1,2rnby1 .. LIA-5M .
Registration No. c�
Operator's ignature
_]
Please grin[firmly '
1OM-8/81.164843
,I <,%w6LG- FAMILY
Wo GAlZ5A-&E 69jNRE2"='
p/al t•.Y F L O W 1 1 0 X 3 = 33 O G.PD , /�L.41V
SEPTIG .TANK = 33Ox15o0/- = '4956.PQ ,C�'�Ci�
y5E- 1000 GAL.
0%5Po5AL PIT v5E I000 GAL.. :
5%prLWALL AQGA. = I!�OS.F
�5D $.F• l� �•5 r 37 5 G.P D ,�it/G��;�� 'T.i���C�4�'��t/O /y�e�iGL,5
BOTTOM ARV-Az.. �O 5 F•- ,L� 7�- /Tfi//�/ZG�".o�TyE� E�
o G.P o• .S��t/iT1{,QySy.SrE�+j ,�tN17 .vo .S4.c�ir.•�Zl� I
•ToTAl-. pF.51GNV .425 G.PD. 'o� TNT
-T oT AL TD A I I-Y
PER.Co�.ATIoN RATE ] I''IN 2MIN o�Lr�55
N OF lIq ZH OF
L�P� ST4
n� WILLIAM �: Xr o� DAVID ryC.
,� �'fO✓�,4GG G/i6!;cJ/;TAIL E
G
C.
.. 7HUlIN
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No. 19334 � L �A �F 1�0a, ' .c/G.�-
Fo�s �� moo` ST�a
V
a �9�yp S--U�-,v` f ONALE��
l OZ• p To P FWD1000
=IOL i
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1000 INS( // 'Z TANK
! Z/ LEAGN y8 G'
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LOCt .T D 'WI NIIg
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REG I SZ E26U'�.N o 5�ev r,�Yoes �
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5
� IlJS•1-R•�MEI.IT �,�2vtrY 'THE UI=FSETS suouLD
NOT DE VSED•TO Q'%I � LcT - INE.�j APPI.IGA►JT L'!t'�" .�-s%.�An� ` ; F
I po G Gy'f
� Sao-3
r� a
Ab.,
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t
'IO'W1 C1F BARNSTABlLE.
LOCA'X'iOl+i e .kl C r r SEYJAGE#
VIILLA Gi%S R+�gmol `S MAp�a LOT
D�STAa EIt`S NAME& HOIG1+IO, f
SfiI UC TAN C CAPACITY r'` I
�0v Gil
,cI:mGac�r�t ct )' l-lam a% P,f cs� � ---..
cJ '.
�B.IIl,IG Elk 0
d1N1 Eft`.
PBRNdi(Tt.3A'I CfSPOLIA►N I7 TE -. -'
S�cratioa� a Bstvieen the. : :: �
Ivlxi ►um Ad�usti;Graii�eciwater Tablen tha MI..
PilvaB�ilAter Y iNcid PH�:t�►�6aiag 1�acwlity �n�y►wells a�
ot�sets ce wtttun 2AQ feat pP l+aach as
wetWds exist
F,ti�r of A1etid and I;oactn Pactlit3+ uety" Il�ee
alit 00 0 0 tophiag:�'icAty) T�Z
o
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a
9-5. 6 7,
G�C� �76 '