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HomeMy WebLinkAbout0049 RIVER RIDGE DRIVE - Health 49 River Ridge,Drive. Marstons Mills ` LA = 059 009015 i i r >� Commonwealth of Massachusetts Title 5 Official Inspection Form �'' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 River Ridge Drive _ Property Address Lynne Deliso Owner Owner's Name information is Marstons Milss _M _ required for A_ 3/29/2013_ every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: I only the tab key ',} to move your _Wayne Archambeault , cursor-do not Name of Inspector J v use the return key. Company Name r� PO Box 914 _ Company Address Hyannis _ MA --- 02601 City/Town State 0 Zip �Co C) 508-775-1362 _ 355 Telephone Number _ License Number n. B. Certification CID I certify that I have personally inspected the sewage disposal system at this add less and th'at th y 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 Loc I.Ap roving Authority 3/29/2013 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the7inspector 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. i t5ins•11110 Title 5 Official Ins ectwn 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 49 River Ridge Drive Property Address - L ny ne Deliso Owner Owner's Name information is Marstons Milss MA required for _ 3/29/2013 every 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: 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11110 Title 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 49 River Ridge Drive_ Property Address - — - -- Lynne Deliso Owner Owner's Name - information is required for Marstons Milss MA _ 3/29/2013 _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f ItN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 River Ridge Drive Property Address -- Lynne Deliso _ Owner Owner's Name -- information is required for Marstons Milss MA _ __. _.__. 3/29/2013 every page. City/Town 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. ❑ 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 ❑ 0 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 t5ins•11/10 Title 5 Official Inspection 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 ^M 49 River Ridge Drive Property Address Lynne Deliso Owner Owner's Name — — — information is Marstons Milss MA required for _ 3/29/2013 every page. CitylTown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 49 River Ridge Drive Property Address -- ----- —---_- ---- Lynne Deliso Owner Owner's Name ------- -- ——'--- —--.—— information is Marstons Milss MA 3/29/2013 required for --- ---------------_.._.. --- every page. City/Town 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 t5ins•11110 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 49 River Ridge Drive _ Property Address Lynne Deliso Owner Owner's Name -- information is Marstons Milss MA required for 3/29/2013 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: .- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): — — Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 3/29/2013 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -- 49 River Ridge Drive Property Address — -� Lynne Deliso — -- - — - -- caner Owner's Name information is _ Marstons Milss MA required for -� 3/29/2013 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner - --- Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M- 49 River Ridge Drive Property Address — — - Lynne Deliso Owner Owner's Name -- - information is Marstons Milss required for _ MA 3/29/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 2/11/2005 permit#2005-077 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4' 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: 3'feet - Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) riser within 10"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'x5'x5' Sludge depth: 2„ t5ins•11/10 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 e 49 River Ridge Drive Property Address Winne Deliso Owner Owner's Name - _ -- information is required for Marstons Milss _ MA 3/29/2013 every page. Cityfrown 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 38" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" — How were dimensions determined? measuring rod 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 appears to be stucturaly sound , tees at proper heights Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e `- 49 River Ridge Drive Property Address - -"— - -- - - Lynne Deliso Owner - - -- --- Owner's Name - - - information is required for Marstons Milss MA _ 3/29/2013 every page. CitylTown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 11 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 River Ridge Drive Property Address -- -- Lynne Deliso __ Owner Owner's Name information is Marstons Milss MA required for __ 3/29/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): box level and water tight 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 lit Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 River Ridge Drive Property Address -- - - -- Lynne Deliso _ Owner Owner's Name -- --- information is required for Marstons Milss MA 3/29/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® Teaching chambers number: 2 ❑ 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.): no sign of stain line or liquid in chambers 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 It Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 49 River Ridge Drive Property Address -- - --- -- L nne Deliso Owner Owner's Name - --` - ---- information is required for Marstons Milss MA _ 3/29/2013 every page. City/Town 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•11/10 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 49 River Ridge Drive Property Address - — -- Lynne Deliso Owner Owner's Name -- - information is required for Marstons Milss MA 3/29/2013 every page. City/Town 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION Y'r i2w C-ite I. SEWAGE 0 I?a))-D vm"rr M.1s ns .41, ASSESSOR'S MAP&LO 9 1S INSTALLER'S NAME&PHONE NO. �+. SEPTIC TANK CAPACITY ��yr- LEACHING FAC]TTY:(type)•73(2:SAT A, (size)/:��"Xa✓X,;' 999 NO.OF BEDROOMS 3 BUH-DER OR OWNER PERMIT DATE: :;I3YAD S COMPLIANCE DATE:_T /o4 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility `� Feet Private water Supply WeU and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ._ within 300 feet of leaching facility) Feet Furnished by +sf'it-K ar rtv�x JAAd IC � I 31 A. yr j J o httt)://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappa1=059009015&seq=1 3/26/2013 Cn ITO 7t11-i i Commonwealth of Massachusetts J W Title 5 Official Inspection Form +- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 River Ridge Drive Property Address - -- -� — nne Del Owner Owner's Name — --- information is required for _Marstons Milss _ MA _ _ 3/29/2013 every 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: 20 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: TOB GIS data water at 20' bottom SAS 5.5' seperation from water 14.5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 49 River Ridge Drive _ Property Address ---_ Lynne Deliso _ Owner Owner's Name — -- information is — required for Marstons Milss MA every page. City/Town 3/29/2013 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of.17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 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. Imng out forms A. General Information filling out forms f on the computer, D �f use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David Mason � Company Name 4 Glacier Path Company Address � East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number . B. Certification I certify that I have personally inspected the sewage disposal system at this addressaand that-1 --4 i information reported below is true, accurate and complete as of the time of the inspection. The-Pnsperstion was performed based on my training and experience in the proper function and ni'd tenance of on st"f sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000).The system: —.. wco ® Passes ❑ Conditionally Passes < ❑ Fails 5-1 ❑ Needs Further Evaluation by the Local Approving Authority 0 _= s-- M b6ow* %U&JAJ� March 12, 2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. L't I/ L� I �I t5ins•11/10 Title 5 Official Inspection For :ISsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is required for every Osterville MA 02655 March 12, 2012 page. Cityrrown 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: ® 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: This inspection information represents the condition of the system on March 12, 2012 at 7:30 AM and only that date and time nor does the inspection guarentee the future operation of the system. 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. City/Town 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. ❑ 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 Y2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official a Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is required for every Osterville MA 02655 March 12, 2012 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•11/10 Title 5 Official 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 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. Citylrown 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 t5ins•11/10 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 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is required for every Osterville MA 02655 March 12 2012 page. Citylfown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2010; 258,000 gallons and 2011: 180,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current 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•11/10 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 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is required for every Osterville MA 02655 March 12, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): . General Information Pumping Records: Source of information: Barnstable BOH 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•11/10 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 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: March 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments(on condition of joints, venting, evidence of leakage, etc.): No observable problems Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) riser to within 10 inches of grade If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Typical 1000 gallon tank Sludge depth: • 2" t5ins•11/10 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 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. Cityrrown 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 38„ Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Outlet tee in adequate condition. Portions of tank observable appear in adequate condition 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•11110 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 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is required for every Osterville MA 02655 March 12, 2012 page. Cityrrown 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•11/10 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 ,M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osteryille MA 02655 March 12 2012 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert half inch 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.): Effluent was a half inch above outlet inverts due to running water into tank from use or leakage in the house. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Standing effluent in the chambers. There was approx 6 inches of effective leaching area remaining. Increase in occupancy and or use may result in hydraulic failure. Excessive amount of effluent being held considering the age of the system, but effective leaching area remaining allows the system to pass. Water use records indicate that the use of water exceeds the design capacity of the system, but the remaing effective leaching area allows the system to pass. 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•11/10 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 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is required for every Osterville MA 02655 March 12, 2012 page. City/Town 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. Citylrown 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 t5ins•11110 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 �M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is Osterville MA 02655 March 12 2012 required for every , page. Citylrown 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: 25 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: As-Built 3/11/2005 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: gourndwater contour map and septic designs in the area Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 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 ;M 49 River Ridge Drive, Marstons Mills, MA Property Address Lynne Deliso Owner Owner's Name information is required for every Osterville MA 02655 March 121 2012 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 :47-T TAAi K 31 ' ��r3CX 3 � . Ns`' INWisplrty.;tsp:'rn<tpp;ir=O;i< c - IOOJO1 &-tied=1 TOWN OF BARNSTABLE LO A—' ION qcf L6i i-r Ulei N SEWAGE # d005 d 7d -MMLAGE s.o n5 IT t ASSESSOR'S MAP & LOT r "'15 INSTALLER'S NAME&PHONE NO.002.e:Q+:Aoutf, 5,01141 ik.*yr z' S47 2)S—YZX- SEPTIC TANK CAPACITY &XIIrce�. LEACHING FACILITY: (type) 0)(S"?�: rtr�..ee,r� (size)),,1,C,'(�V x0 NO. OF BEDROOMS BUILDER OR OWNER ����5 0 PERMTTDATE: ;213- V0 S COMPLIANCE DATE:it Separation Distance Between the: w Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility � ! Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) _ f Feet Furnished by P.6 ��S V IAAIK 31 t ollwc 5� i No. U .Z. ,s _ 4100 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for loioponl *p$tem COtt!gtruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 4 2 0—2 7 4 3 49 River Ridge Dr, Marstons Mills John Deliso Assessor'sMap/Parcel ps-I_ t _ UI S;— 49 River Ridge Dr, Marstons Mills Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Service Eco—Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 1 e a r-h system to plans of Eco-Tech. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this B ealth. Signed e Dat Application Approved by '�✓ Date Application Disapproved for the following reasons Permit No. V fy' —U 7 x Date Issued —2,&_y S— No. aUUS. 0�2 �� Fee1O0.00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS application for 30igP0541 *P.5tem Construction Permit Application for a Permit to Construct(, )Repair(X)Upgrade( )Abandon( ) ❑Complete System El Individual Components i at ; Location Address or Lot No. Owner's Name,Address and Tel.No. 4 2 0—2 7 4 3 . 49 River Ridge Dr, Marstons Mills John Deliso Assessor'sMap/Parcel OSI— QIJ 6�— Ol S� 49 River Ridge Dr, Marstons Mills Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's_Name,Address and Tel.No. 3 —0 8 9 4 Wm E Robinson gr Septic Service Eccr-Tech PO Box 1089, Centerville 43 -Triangle Cir, Sandwich Type of Building: Dwelling No;of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures A Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when ap licable) Install a new Title 5 leach ` system to plans o Eco-Tech. r S Date last inspected: 4 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system. in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued t�s B&, ealth. ,. Signed n Dat'Z Application Approved by X Date Application Disapproved for the following reasons Permit No. U S 'U 7 °Z Date Issued THE COMMONWEALTH OF MASSACHUSETTS Deliso BARNSTABLE, MASSACHUSETTS (Certificate of (Eompliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired (X ) Upgraded( ) AbandQQned( )by Wm E Robinson Sr Septic Service at 4y River Ridge Dr, Marstons Mills has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �/CV �OG?a dated Installer kc b/nSor Designer .� La no L) The issuance of t ' pe t shall not be construed as a guarantee that the system will c 'on as designed. Date '" -� Inspector No. gw5 --o 7 FA100.00 Deliso THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS .i &!6ponl *p!5tem Congtruction Permit � Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) Systemlocatedat 49 River Ridge Hoive, Marstons Mills 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 p rrn t. " Date:_ a / Approved by i J Town of Barnstable �0ftHE 1ph, Regulatory Services Thomas F. Geiler,Director + BARNgrABLF. MASS. Public Health Division �A i63.q. A�0 TEv Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: j✓ t Designer: Eco-Tech Installer: Wm E Robinson Sr Septic Service Address: 43 Triangle Cir Address: po Box 1089 Sandwich Centerville On a,� O�--Wm E Robinson Sr Sep y,&s issued a permit to install a (date) (installer) Service septic system at 49 River Ridge Dr, Marstons Milll4ed on a design drawn by (address) Ecn-T,mrh dated a( t) (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. �kviH OFMgss (Installers Signature) OUGI * �r{,R cy_ 993 YS (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form c TOWN OF BARNSTABLE LOCATION �/ol Qi�V�� .af�, �r ` SEWAGE # pfG'�0 �� VILLAGE_ /�: s �1'1 t I IS ASSESSOR'S MAP & LOT� 9 is INSTALLER'S NAME&PHONE NO,WM.e: SEPTIC TANK CAPACITY ' ;bcy-► c,, LEACHING FACILITY: (type NO. OF BEDROOMS BUILDER OR OWNER O 'so PERMTTDATE:- ®3�It�S COMPLIANCE DATE: �o Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility `, Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Gss ii w JA4 no K .31 ' ; 37` LIS ° ��yell f A `o� ,dot TOWN OF BARNSTABLE 6� LOCATION 121 j/L-7Z W:;,C SEWAGE VILLAGE --� � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.A`Z-rpJ,,::nr '( C 77j.-jZqj SEPTIC TANK CAPACITY = LEACHING FACILITYAtype) i-C (size) (zk!p , NO. OF BEDROOMS PRIVATE WELL PUBLIC)WATER BUILDER OR OWNER 1 DATE PERMIT ISSUED: '' DATE COMPLIANCE ISSUED: oh 19 VARIANCE GRANTED: Yes LfNo 35 ` AP O l X V- nF. .....:La. ...... 91 -THE COMMONWEALTH OF MASSACHUSETTS ".cEl BOAR® OF HEALTH 20 _ TOWN OF BARNSTABLE Aliji iratiun for Dhipuua1 Workii Tunuttrnriiun Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal ein Syst.....a_...............1/...�......1. ��9 ...! ... ••-- -------------------------------------------------------•----- o io -tldd 1 or Lot No. ... -• • •••... • ...............•....•••-•-....._...._...._...................... .... ..............................................._...... W O er Address . .--•-•-•• .......................................... ....................------... --.....----.....................••........ H a k Installer. Address s G d Type of Building Size Lot.... ----Sq. feet Dwelling—No. of Bedrooms-...... _�----. -----Expansion Attic ktQ Garbage Grinder (vv) Other—Te of Buildin "`—Other—Type gW ..... No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------- --•-------------------------•---------•------------------.....---------...........---• W Design Flow..................ILQ..............._gallons per pcpsmr per day. Total daily flow-------- :�P........................gallons. WSeptic Tank—Liquid capacity.14Mgallons 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 nk ( / / �7 '~ Percolation Test Results Performed by..--1% y ---- ------------4 --- Date <-• f-- � ® Test Pit No. I...:!�.cP-_.-minutes per inch Depth of Test Pit...................• Depth to ground water....C...... ... f3, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •• .................... -- ---•-------•••--------------------------•-•.....-------•_•-•.••......................................................... ODescription of Soil......• --- ............................-........................................................................................ rJ ----------------------------------------------- ----- •-----------------------------------------------------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 Environmental Co 1�,� The u ers ed further agrees not to plac the system in operation until a Certificate of Com fiance has` bM Signe ---- - .............--- ....... ... .......... ---------- ApplicationApproved By ............ ....`!D. ----------------------------------------------------------------------------------- ..... Da1...� � ��- te Application Disapproved for the following reasons- ............................. - ------------------------------------- ------------------ -- -------------- --------------- --------------------------------------------- ---------------------------- -------- ------------------ --------------------------------------..................................----------------- ----------------------- ---------- Permit No. -------- ---- - ---------------------- Issued.........................................................Date- ate Date O 59 THE COMMONWEALTH OF MASSACHUSETTS ooc) old BOARD OF HEALTH 3 TOWN OF BARNSTABLE Appliration for Biipnaal Workii Cnnn.itrurtinn Prrmit . Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage-Disposal Systein at: ..... ... • .-•--_. ..... Jo�ion/Address r Lot No. /� " o Ow(zer —Address N r�Installer Address r d Type of Building -" J Size Lot_.__ 7__-�� `.....Sq. feet Dwelling—No. of Bedrooms.......... .............................Expansion Attic (it{.1) Garbage Grinder (11)) Other—Type of Building A.1M /_ No. of persons............................ Showers a YP g --------•-----•----•-•-•--- P ( ) — Cafeteria ( ) Other fixtures ............................................ � --------------------------------------- w Design Flow...................//.0_...._._.._...._gallons per persorrper day. Total daily flow..._..._�3.�.�-�._____...................gallons. WSeptic Tank—Liquid capacity.. M 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 t, nk �(, n)` 7� - / '-' Percolation Test Results Performed by.-......... y �v Date /--yl�'r�--- ---- --- - Test Pit No. 1___!< .._minutes per inch Depth of Test Pit.................... Depth to ground water.__. !........... 4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•-------------•------------------------•---•--•••-......---•--.......................................................... Description of Soil...... = '�r't'v� ......... c, --•--•--••----•-•---••----•--••----•-•----•----•--------•-•---•-•-------•-------•-•••-----------•--•-••-•-•-•------•••-----•--.-------•--------...•--••---•••-•----•-•-----•---•....__...-••--------- w UNature of Repairs or Alterations;—Answer when applicable------------------------------------------------................................................ r Agreement: t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE,5 of the State Environmental Co e—The un ersigned further agrees not to place the system in operation until a Certificate of Com liance has . by. Signed ..... ......... /•-_1 x----.—�-"'f ---------- ------------ Applications�....... .... ..................... ApprovedBY - '^ ,.." ---------------------------------------------- -------._-----_-_----...... -----... Date Application Disapproved for the following reasons- --------- --- ------------------------------------------------------------------ -.....................------------------------- ........................................Date PermitNo. (1?--tz-------------_---_ Issued ................................----------------------- --- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gertift>raite of Cgompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V ) or Repaired ( ) ` .. �D .by. Ins[aJlec. at . .-.r.;'.1.....................j...... 61tf.-`AA&P --- ..................�. .....:.... ---...----------------....-- --......--------------------------..........------ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......... - ..-. -.1-- ...... dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. g� q' .- ,,.................... ...... . ? ='` --------------------- DATE 1 Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE / FEE._.....l ...... Dhipaoat Workii TowAr ivit rrmit Permission is hereby granted jj -------------------------••-----•-----•-•-•------------.....--------------------.......---------•-----•.................•••- to Construct (, V) or Repair ( ) an Individual Sewage Disposal Sy tem at No .................... .-•------------ ............................................................ Street as shown on the application for Disposal Works Construction Permit o..f2t (5� Dated........ .................................. ........................ ------ -- may Board of Health DATE------------- ------•------•----/ ------ ....... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS FLOW PROFILE ALL PIPE ELEVATIONS SPECIFIED ARE INVERT ELEVATIONS VENT PIPE TOP OF FOUNDATION RAISE COVERS TO WITHIN EL - 6250 +- 6 in OF FINAL GRADE rl ONE INSPECTION RISER FOR LEACHING GALLERY /D BOX MAX 2' LAYER 1/2- STONE OF I%8- 3- DROP r - FLOW LINE 10- = 14" 48- GAS�� PRECAST 3/4-4 1/4- BAFFLE - DRYWELL STONE 57.80+- 6 in BOTTOM OF oosrnw STONE 57.SO LEACHING SOIL ABSORPTION �asnNo BASE SYSTEM EXISTING 57.6' GALLERY 57.40 oc�sTNc 1000 GALLON (END VIEW) 5S.40 5.00 rr • P� D(IST"G SEPTIC TANK 2.8 i, lz a) 5 f, 12.5 fr b) 12 f, � `�� ESTIMATED 35.1 '. SEASONAL HIGH GROUNDWATER <o � Z V i n O y z o = 9g � p > ' cND fU O O ZCID T� O 70 o, • .ta o wm ./ ® X N ail VIA r E M 7p ° M --A187 !t O, m , NT Z O 1N'v a�n Z �j szt m D , Z m � ' 3 SyF� m O 7n, � T T m 00 \\ r�db as go 0 --4 o�cv �i to In jJ 95'IZI S1 0 (0z ON 9�9� Ul oho O 0' N� �� �D r mZ oo z T = m °� Gn = 4 f-m -I O (n O rrI r-3 m m Z v7Oi H m (11 R1 cfl r7'� f11 x to 00 k O>N �� n 'a ay o you �'' ��rn m _r 00 1 ; r � Z z� x nT z m . ov'D m 4-4 � � � -< m T y � ~ �r� � tn�m , n W?�0 -n 0 m m cmn z 6 A OOO n = m z m U5 Z � 3 m �o (Tl 'ose_ ^—' A _w m m p zX z� m v> 3� p cpFe v � � c 3 3 Z � O ® � ® 0 o �� n Z 4 " F�Sy�o Z rn�!o 0z � � p G) cn - � � Z o � a» 00 o _n_4 m o � o � —� -4 3 r-,Z tp Z o �— �'--r z ' O O r- � R a MAC) 3 rc: DRIVE Tl 3 y a z � zr � z � o , U) oa a o Z m p —I 1r, G) r- -0 m yy O c 5v�� � IV � ti oVma N r— 3 Z mo M 9 0 d SOIL TEST - LOG - DESIGN CALCULATIONS DATE OF TEST: FEBRUARY 14. 2004 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD g WITNESS REQUIREMENT WAIVED - NO VARIANCES SOUGHT NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS TEST PIT I - PARENT MATERIAL: PROGLACIAL OUTWASH ELEVATION - 61.70 PERC AT 78 in : 2 MIN/INCH IN C- SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL •- CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX. (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 61.70 SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 0-6 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE A b o t - ( 24 x 12.5 ) - 300 of 6L20 6-142 C MEDIUM TO 10 YR 6/3 NONE LOOSE Asdw - ( 24 ; 24 12.5 - 12.5 ) x 2 - 146 of COARSE SAND A t o t - 446 of 49.87 Vt 0.74 x 446 - 330.04 GPD USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt. - 330.04 GPD > 330 GPD REQUIRED GROUNDWATER ADJUSTMENT EXISTING GROUNDWATER LEVEL LEACHING GALLERY BASED ON TOWN OF BARBSTABLE GIS DEPARTMENT RECORDS. CONSTRUCTION DETAIL INDICATED GW 28.0 YWELL UNIT . ( STONE INDEX WELL SDW-253 a•-O'x 4•-10-x 2-n-J ZONE C 2 (1 EFF. DEPTH READING DATE JAN. 2005 24.0 ft READING 51.1 ADJUSTMENT 7.1 ° ADJUSTED GW 35.1 M o . _ N N N _ o NOTES M 3.5' 8.5' 8.5' 3.5' I) GRINDER NOT ALLOWED WITH THIS DESIGN 24.0 ft Nor TO SCALE GARBAGE 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 3) ALL COMPONENTS OF MASSACHUSETTSTTITLED5SHALL MEET SEPTIC CODE THE (310 MINIMUM CMR SREQUIREMENTS 500 GALLON DRYWELL 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES DIMENSIONS AND DETAIL BEFORE EXCAVATING FOR SYSTEM. USE H-10 LINTS 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE MTALL ONE MPECTION RZER TO W r N SIX S OF ADE 7) LINES EXITING D-BOX TO RUN LEVEL ,FOR 2--0- BEFORE PITCHING DOWN �p MICCATTELOCA�r ON 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE -INSTALLATION OF LOW FLOW FIXTURES AS-BOLT PLAN SEWAGE DISPOSAL SYSTEM PLAN AND APPLIANCES. AND BIANNUALY'P�UMPING OF" THE SEPTIC TANK -TO SERVE EXISTING DWELLING 9) SYSTEM IS NOT DESIGNED TO WITH.S:TAND VEHICULAR LOADING. DO NOT 34 PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. o�pboo 00 �0$Op in LYNNE M. DELISO 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 0000a0000ao 000 c 00 oq 00 49 RIVER RIDGE DRIVE MARSTON„ MILLS. MA 1 1) SEPTIC TANKS _SHALL BE INSTALLED LEVEL AND TRUE .TO GRADE ON A LEVEL �cz) 8 STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH ECO-TECH ENVIRONMENTAL `;SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 1p2 in 12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED 43 TRIANGLE CIRCLE SANDWICH MA 02563 FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. ETE-1918 FEB 21. 2005 2/2 „ _ , _ _ e. ° Y ; ! i- I I T-T-' -1- --I-- - I - r -I--' _ __ _. J.. -! .... ._. ,-. I. - _- r. = ., ,!-..e. f -( -, i-t -, i 1 -r T i -I r I r r I i .- i- .1_ -s 1 .♦.ix. -� -!- -i- , -r I . .j I. ! ! I. __L , ,. _I _ f ..i ll ._ �..i..! _ ' it.._,_r _ _:� __ }V * L-,� ..-- t._._l__I_: ..-j-..1�.:_.,_..._ __ _ I 1 !- 1-' L_ --�( -• ; :_, 1. ! _ .._ _ i !-�I ! 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