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Home My WebLink About0152 RIVER RIDGE DRIVE - Health 152 RIVER RIDGE DRIVE, M. MILLS A = 059 007.005 r i I �I TOWN O_FQBARNSTABLE n LOCATION VILLAGE ASSESSOR'S MAI&PARCEL IN%�' �S NAME&PHONE NO. f f l Ic SEPTIC TANK CAPACITY 1 .500 LEACHING FACILITY:(type) (size) k 000 NO.OF BEDROOMS OWNER77 ofe PERMIT DATE: C DATE' f y IQ 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 4 \ \'4 \ 4 4 4 \ k h \ k \ h 4 ♦ \ ♦ \ \ \ ♦ h 4 \ 4 J h/\FhlhJ4FhFhfhf /4f4f f f f f f F F J f f f J f J F �'F hJ\ hF4f\f\f\f\!hf\ 4 \ 4 4 4 4 \ \ \ \ \ \ h \ 4 fh f F f f f f f 4 4 4 \ h 4 4 4 \ \ h \ h h 4 4 F f f f ! f J f ! /4f 4 4 / 4 4Fhfhfhl4/\Fh h h h 4 \ 4 h f 4 h 4 \ h 4 4 \ 4 4 \ 4 4 \ \'\'\'\'4'\'\ \ ! 4 \ \ \ ! ! 4 \4+\ \ h 4 4 4 \ \ 4 4 \ h \ \ 4 4 \ 4 \ 4 4 \ \ \ \ 4 4 +� \ \ \ 4 4 \ \ \ f J F f f f f•! J'I F / f 'f f f f ! ! J / J ff f f f f d ! f f l ! d ! 4 4 4 4 t' 4 4 4 4 \ 4 .4. \ 4 \ \ 4 \ \ \ \ • \ \ \ 4 \ \ \ • 4 % \ \ \ f F f ! f f f J 4 �x�•..,. f J / / f f f ! F " ! f�f 4 4 \ \ 4 \ 4 4 4 4 J f f \ \ 4 \! f\ \.4 3 f ! ! lfff 45 r 41 1 TOWN OF BARNSTABLE LOCATION s� SEWAGE # VIl:LAGB /,(Jt� .L�B ASSESS 'S MAP& LOT ZAl l}i✓GT(QS` AME&PHONE N O SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 1d0a NO.OF BEDROO BUILDER O OWNER T PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 0'u'' Commonwealth of Massachusetts w0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 152 River Ridge Road Property Address Priya &Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 July 14, 2012 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. Important: A General Information Whenn filling A.ng out forms on the /1 computer,use 1. Inspector: (� only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 S1 12855 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 1.5.000). The system.- 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority R . July 14, 2012 In a or's Signat re 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. VW Pq11-99 Gore 152 River Ri.doc•08106 Title 5 bsurface Sewage Disposal System I.P 1 of 15 Commonwealth of Massachusetts w r r Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 152 River Ridge Road Property Address Priya &Matthew Gore Owner Owner's Name information is required for Marstons Mills MA _02648 July 14, 2012 every 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: ® 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: Tank was scheduled for pumping folowing inspection. Leaching pit has 16" of standing water with no high stains. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 11-99 Gore 152 River Ri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya &Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 July 14, 2012 every page. CityfTown State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. 11-99 Gore 152 River Ri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya & Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 July 14, 2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 El ® 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_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 11-99 Gore 152 River Ri.doc-06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 July 14, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 11-99 Gore 152 River Ri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is requiredfor Y Marstons Mills MA 02648 Jul 14, 2012 : every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following.- Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 111-99 Gore 152 River Ri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 July 14, 2012 every page. City/Town State Zip Code Date of Inspection 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 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A irrigation g ( y g (gpd)): system. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑. Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): - 11-99 Gore 1152 River Ri.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya & Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 July 14, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 3 years ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe).- Approximate age of all components, date installed (if known) and source of information: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No 11-99 Gore 152 River Ri.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''r 152 River Ridge Road Property Address Priya &Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 Jul 14, 2012 required for Y every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 4" � Distance from top of sludge to bottom of outlet tee or baffle 26 Scum thickness 3" 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 10" How were dimensions determined? Measured 11-99 Gore 152 River Ri.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 152 River Ridge Road Property Address Priya &Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 Jul 14, 2012 required for Y 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.): Liquid level was found at bottom of outlet invert and baffles were intact. 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 I 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): 11-99 Gore 152 River Ri.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 152 River Ridge Road Property Address Priya & Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 Jul 14, 2012 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): No solids or high stains present. Liquid level at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 11-99 Gore 152 River Ri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 f `<C\, Commonwealth of Massachusetts Title 5 Official Inspection Form Fj Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya &Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 Jul 14, 2012 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit had 16" of standing water at time of inspection with no high stains or evidence of surcharge. 11.99 Gore 152 River Ri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 IL f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 July 14, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 11-99 Gore 152 River Ri.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 r _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya & Matthew Gore Owner Owner's Name ------_....--- - ........... information is Marstons Mills MA_ 02648 July 14, 2012 _required for _ _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System.- Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. River Ridge Drive Water Service 3 45 41 1 i I r t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 Jul 14, 2012 required for _ y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 30+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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 25 and topo map shows property above el. 70. I • 11-99 Gore 152 River Ri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 019 TOWN OOF�BARNSTABLE LOCATION �` ��l /L �-� SEWAGE# VILLA E "' M LL s ASSESSOR'S MAP&LOT /A/S P£e o/L IN*+AttER'S NAME&PHONE NO. C /j SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER �� A PERMIT Dom: --e,;2 4� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 EAR e , �I t P `r "a TOWN OF BARNSTABLE LOCATION RiQ-r 'VILLAGE MGVVDAS MLJ15 ASSESSOR'S MAP&PARCEL NAME&PHONE NO. e fi L L O, o N 101`7 0/ r SEPTIC TANK CAPACITY J 5''00 LEACHING FACILITY:(type) �I� (size) 1000 NO.OF BEDROOMS OWNER ?^ 'PERMIT DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lea chi 1 Feet FURNISHED BY \ 4 4 \ \ \ \ • ♦ \ \ \ \ \ \ \ 4 \ 4 \ \ J P F f f f f P f f f / I f I ! / l f f.. . r f % 4 \ 4 4 4 \ 4 4 • • 4 \ • 4 \ • )f • 4 4 \ 4 4 4 4 \ \ \ 4 \ \ 4 4 • ^ r f r f r r f F r F r F r h \ 4 4 \ \ \ \ • 4 \ 4 4 \ \ \ \ \ h h • 4 \ \ k 4 \ 4f 4/414/4/\f 4!\!\ 4 ! \ \ \ \ 4 4 • \ \ • \ \ 4 A \14/\f\J4/•I\f\/\ \ r f r s r r f r r f r I I ' 4 \ \ • \ \ \ \ \ 4f\f\f\J\f4f4f4/•/4 4 h \\.1�\y\ \ • \ 4 \ \ \ \r\/•f•f\/\/4J41. \ 4�C • �I•f4f\!•/•! 777 3 45 41 1 ASSESSORS MAP NO: (�Z 007— Commonwealth of Massachusetts D PARCEL NO: S Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 June 26 2009 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information forms on the (� computer,use 1. Inspector: J 1 t ��q only the tab key to move your Patrick M. O'Connell cursor-do not. Name of Inspector use the return key. Septic Inspection Services Co. Company Name VQ 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June 26, 2009 In pector's Signat 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. � 09-131 Gare.doc•08106 Title 5 Official Inspection Form:Subsurfalewageisposal Syste •Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments k1wil, 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 June 26, 2009 every 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: ® 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: Tank is not in need of pumping at this time, leaching pit has 14-16" of standing water with no high stains. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 09-131 Gore.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road Property Address Priya &Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 June 26 2009 required for � _ every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. 09-131 Gore.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 oA 15 INN Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya &Matthew Gore _ Owner Owner's Name information is required for Marstons Mills MA 02648 June 26, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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_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. 09-131 Gore.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore _ Owner Owner's Name information is required for Marstons Mills MA 02648 June 26 2009 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. 09.131 Gore.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 June 26, 2009 required for i 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)] i 09-131 Gore.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 June 26, 2009 _ every page. Cityrrown State Zip Code Date of Inspection 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 — 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): — Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — Last date of occupancy/use: Date — Other(describe): — i I 09.131 Gore.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road — Property Address Priya&Matthew Gore — Owner Owner's Name information is Marstons Mills MA 02648 June 26, 2009 — required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 18-24 months ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1988 — Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-131 Gore.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore _ Owner Owner's Name information is required for Marstons Mills MA 02648 June 26, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No •-------------------------------------------------------------------------------------------------------------------------- Dimensions: 10.5' long x 5.8'wide- 1500 gal._ Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 30" — Scum thickness Trace — 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 14" How were dimensions determined? Measured _ 09-131 Gore.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of•.15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 June 26, 2009 every 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.): Tank is not in need of pumping at this time, tees are intact and clear. Liquid level was found at bottom of outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): 09-131 Gore.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 June 26, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: — Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): No solids or high stains present. Liquid level at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-131 Gore.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owners Name information is required for Marstons Mills MA 02648 June 26, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. _ ❑ leaching chambers number: ❑ leaching galleries number: — ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: — ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit has 14-16"of standing water with no high sidewall stains 09.131 Gore.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 r - Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 152 River Ridge Road _ Property Address Priya &Matthew Gore Owner Owner's Name information is required for Marstons Mills MA 02648 June 26, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer — Dimensions of cesspool — Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions — Depth of solids — Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 09,131 Gore.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I ' N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Priya&Matthew Gore Owner Owner's Name information is required for Marston Mills MA 02648 June 26, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. River Ridge Drive Water Service „ rrr , r , rrrrr „ , , rrrrrrr , , r rrr rrr rrr rrr rrr r r r r r r r r r r r rrr r r r r r r , r r r r r r r r , rrrr . , r r „ rrr r r r r r r r r r r , r r rrr r „ / rrrrrrrrrrr , rr , rrrrr , rr , , , ♦ , , , ♦ „ / r r r r r r r r r r r r r r r r r r r r r r r r r , ♦ , , ♦ , , , , , . , , ♦ , , , , , , ,., , , , , , , , , , , , , , , , rrrrrrr „ 3 45 41 1 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 152 River Ridge Road Property Address Pia&Matthew Gore Owner Owner's Name information is Marstons Mills MA 02648 June 26, 2009 required for i 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 ground water: 30+ 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: USGS topo map and town GIs. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 25 and topo map shows property above el. 70. 09-131 Gore.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 tl COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m , DEPARTMENT OF ENVIRONMENTAL PROTECTION �e �OqM SV O V 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION _ cx�7 MAP 059—PARC 007-005 Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner's Name: CLANCY,LYNNE Owner's Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Date of Inspection MAY 25,2006 Name of Inspector:(please print) JAMES D.SEARS �s F� Company Name: A&B Canco ^ Mailing Address: 350 Main Street I , West Yarmouth,MA 02673 . Telephone Number: 508-775-2800 E • i i CERTIFICATION STATEMENT ea —11 I certify that I have personally inspected the sewage disposal system at this address and that the informatio i 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's.Signature: Q1Date: 5-26-06 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****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. 1 Title 5 Inspection Form 6/15/2000 1 f Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 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 CUR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined' please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 r - Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 C. Further Evaluation is Required by the Board of Health:N/A 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 salt marsh 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volume is less than 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 is failed. The owner or operator of an large system considered a significant g Y P Y g Y � 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No If 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? If 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? if Were as built plans of the system obtained and examined?(If they were not available note as N/A) If Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,including the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ 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 CUR 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 FLOW CONDITIONS RESIDENTIAL.( 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 Number of current residents: 3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2005-208,000 GAL/2004-164,000 GAL Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 2004 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: AROUND 1988 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 18" Materials of construction: Cast iron ✓ 40 PVC _ other(explain) Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 2' Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500-GAL PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT&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.): MAIN TANK AT WORKING LEVEL,TANK&COVERS AT T INLET TEE,OUTLET BAFFLE. NO SIGN OF LEAKAGE OR OVER LOADING. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete _ metal fiberglass _ polyethylene other (explain): Dimensions: Sctun 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: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: •f (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D-BOX IS 16"X 16"—26"BELOW GRADE. ONE LINE IN—ONE LINE OUT. BOX IS CLEAN&SOLID. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25,2006 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1000-GAL PRE CAST PIT. PIT AT 4'BELOW GRADE WITH COVER AT 2'. 16"WATER IN PIT,NO HIGH STAIN LINE. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY. LYNNE Date of Inspection: MAY 25, 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells witlun 100 feet. Locate where public water supply enters the building. 317-' 6" `� fr i Title 5 Inspection Fonn 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 RIVER RIDGE DRIVE MARSTONS MILLS,MA 02648 Owner: CLANCY,LYNNE Date of Inspection: MAY 25.2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 13 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _T Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked«ith local excavators;installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: TEST HOLE 1.3' NO WATER. TEST HOLE 3' BELOW BOTTOM OF PIT. BOTTOM OF PIT AT 10' BELOW GRADE. /3 �0 �- 3 Title 5 Inspection Form 6/15/2000 i t I o -BORTOLOTTI CONSTRUCTION, Ii+IC.C. �pFAsr ,9� 765 WAKEBY ROAD,MARSTONS MILLS,MA. 0 C� 508-771-9399 508428-8926 FAX: 508428�I+.'i99 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F' A PART A CERTIFICATION Property Address:/J rG s Date of Inspection: Inspector'sWrite: er's Name and Address: %M ��/ ' CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection`was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal }+stems. The System: _=Passes .� Conditionally Passes Needs Further E lion By the al Aproving Authority Fails - Inspector's Signature: Date:___ The System Inspector shall submit a copy of this inspection report.to the rilr-,,roving authority within thir- ty(30)days of completing this inspection. If the system is a shared system its'leas 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 Department of Environmental Protection. The original should=ra sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: A)SYS M PASSES:- I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria no;evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or rep¢irEga. The system,upon comple- tion of the replacement or repair,passes inspection. . Indicate,yes,nor,or not determined(Y,N,OR ND). Describe basis of&�:xr.,r ination in all instances. If "not determined",explain why not. The septic tank is metal,crocked,structurally unsound, show.;sei:-astantial infiltration or exfiltration,or tank failu:c is imminent. The system will pass,"Inspection if the existing sep- tic tank is replaced with a conforming septic tank as approv(,-d,`)y:The Board of Health. Sewage backkup or breakout or high static water level observed La the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or un:ven distribution box. The system will pass inspection if(with approval of The Board c f F-zalth): . - 1 - d 1 'S'UBSURFACE SEWAGE DISPOSALSYSTEM'INSRECTION FORM PART A CERTIFICATION (continued) y Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Woken pipe(s)_are replaced Obstruction is removed 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 the public health,safety and the environment. '1)SYSTEM MOLL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTr: 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. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIERJY'APPROPRIATE).DETERMINES THAT THE SYSTEM-IS FUNCTION- ING IN A MANNER THAT.PROTECT.THE PUBLIC,HEALTH AND..SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and'°is ithin 100 Feet to a surface a water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is wit1l a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is.within 50 I:eet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from Y." the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below:'The Board of Health should be,contacted to determine what will be necessary to correct the failure. Backupof sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to-the-surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. r Statioj!quid level in the distribution bor above outlet,invert due loan overloaded or clog- ged;SAS or cesspool. 'Liquid depth in cesspool is less than^6"below invert or available volume is less than 1/2 „> day flow. - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL:SYS_TEM INSPECTION FORM PART A , CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. X)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10;000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following, conditions exist: The•system is within 400�Feet of a.surface drinking water,sug�ply' The system is,within.200.Feet of a'tributary.to a`suiface drin iu ;water supply M1 The system is located in a nitrogen sensitive area Interim Welhh a'rotection Area (IWPA)or a mapped Zone Il of a public water supply well The owner or operator of any such system shall bring the system and facilit� to full compliance.with the groundwater treatment program requirements of 3 14 CMR'5.00 and 6.00. !'lease consult the local regional office of the Department for further information. SUBSURFACE*SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ✓/None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volt,mes of water have not been introduced'into the system recently or as part of this inspection. s 1/As-built plans have been obtained and examined. Note if they are not,available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The System does not receive"on-sanitary or industrial waste flo*. ✓ The'site' wa's inspected for signs of breakout. " _ v All system components,excluding the Soil Absorption System, have been located on site. septic tank°manholes were`uncovered,opened,and the interi°oc cif the,septic tank was in-: spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, eepth of sludge,depth of scum: : ' VThe size and location of the Soil Absorption System on''the site lta�oeen determined based on existing information or approximated by non-intrusive methods. 3_ S ,off.± ,yq^'',`'},�t, 4 • . L p `SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System rF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .-PART C _ ` SYSTEM INFORMATION FLOW CONDITIONS RF.CinF.NTLAL• Design Flow:,3�LtW. Mons Number of Bedrooms:2_ Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal User Water Meter Readings;' ailable: Last Date of Occupancy - COMMERCIAi ANDUST iR AL: J) Tylie of Establishmen't:' t< Design Flow:- °{'eallons/day'Grease Trap.Present: (yes or no) Industrial Waste Holding..Tank,Present: ' Non-Sanitary Waste.Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATIO PUMPING RECOIfDS'and source-of information`._ System Pumped.as part of inspection: If yes,volume Pull' ' gallons Reason for pumping: TYPE OF SYSTEMS tic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System-(If yes,attach previous inspection records,if any). Other(explain):.- OXIMATE GE f all components,date installed(if known)and source*of information:' Sewage odors detected v✓h n arriving at the sit -4- 1 'SUBSURFACE SEWAGE DISPOSAL SYSTEM ➢P4SPECT➢ON FORM PART C GENERAL INFORMATHON (coa inued) SEPTIC TANK: Depth below grade: � Material of Construction: ii concrete metal FRP_Other, (explain) Dimisions: Sludge Depth: " Scum Thickness: 5— Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or battle: Comments: (recommendation for pumping,condition of inlet and outlet�or PpIlles,depth of liquid level in-relation to tlet invert,structural integrity,evidence of leakage,e .) Wb / Od An J.1A Af GREASE TRAP:/Vo Depth Below Grade: Material of Construction:_concrete_.—,riietal_FRP_Other (explain) _ Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: _ .Comments: (recommendation for pumping,condition of inlet and outlet tics c:►r,balfles,depth of liquid level in relation.to.outlet invert,structural integrity,-evide.nce-of leakage,etc.', TIGHT OR HOLDING'TANK:--A2—d , Depth Below Grade: Material of Construction:_concrete_metal;FRP_Other(explain) Dimensions: Capacity: gallons Design Flow:_ gallons/day Alarm Level: Comments: (condition.of inlet tee,condition.of.alarni and float switches, DISTRIBUTION BOX: `L Depth of liquid level above outlet invert: Comments: (note if lAvel and distrib lion is equal,evi nce of solids carryc,r,evidence of leakage into or out of box,etc OF ]PIIJW..CHA1ddBEHS: U, - Pump is in working order: Comments: (note condition of pump chambei,condition,of pumps and appurtenances,etc) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOEL ABSORPTION SYSTEM(SAS): � (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Leaching pits,number:Leaching chambers, number: Leaching galleries,number:`' Leaching trenches,number, length: Leaching fields,number,dimensions: Overflow cesspool, number: Comments: (note condition of soil,signs of h drauli failure 1 el of pondi g,condition of vegetation, et ".QAX CESSEOOLS:_Z__)(-) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer'-- of Cesspool: `, Materials of construction: Indication of groundwa:zr: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) r PREY Y: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL.SYSTEM tMA14,CTI®N FORM PAWf C SYSTEM INF(DIIMA't ION (con[;Amc:ol) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent refcrenccs, landmarks or bC101111arks. Locate all wells within 100 Feet. F S a• DEPTH TO GROUNDWATER: r Depth to groundwater: / Feet Method of Determination or pproximation: -7- NP~ ` ^ FnB \ THE COMMONWEALTH -' ~~~S~~'-~^' '~ BOARD OF HEALTH ��/� �� xmm "4 ��/��u��o*4mwu� ��xow� Works To4mi«4x4rtmwn Pgrmi4 Application is hereby made for u Permit to Construct ( ) or Repair ( \ an Individual Sewage Disposal System at: ^ y �`-� ��z�- --------- *�e�-----��----l�V��Z-Ala..... �'�e�u°�---�ay�' ion-Address or Lot No, --------' -' ---------------' ---'�-----_~�--'-�~��---------��--------- "~-.--.--.--------_----`��------'_--'°--'~~-_--`~ � ype of Building Size Lot'�S_175"11...........Sq. feet Dwelling--No. of Bnir000`o-' --------------..IIopmoyio^ Attic ( ) Garbage Grinder ( ) 44 Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) .� Other fixtures_ -----.----.--_._---_._--_--.-----.--.---'.-_---._---_--_---__- Deyign ---'--��}ooaper person flow.-..��m��----.------ Septic Tank—Liquid .galoos Length---------D----- ....... Diameter---------------- ' Disposal Trench -No. .................... Width.................... Total Length.................... Total area....................sg f t. 5ccyaKe Pit No---.---... Diameter.................... Depth b6mp inlet-_'--'_'- Total leaching area..................sg f t. Z Other Distribution box ( ) Dosing tank ( ) '- Percolation Test Results Performed bv-------------------- ..................................................... Date........................................ Test Pit No. L.---.-.m6nutcsycrinc6 Depth of Test Pit.------'-- Depth to ground watcc---._--_. 44 Test Pit No. per inch Depth of Test Pit.................... Depth toground ~atec----'----. -` ..................... .............................................................................. Description of Soil..............................62-A-'�an_r.......... -----------_.-------- ---------------------------------------- ........................''.......`..'...........`..........'..`..................`........`..`'.......'..'......`...................`......................`..`.....'....`............. `..........'. .---.-'''-------_---_-''''-'-'-_.-.---.--------'_--_-.----_-''--'--.-----'--'----__.- U Nature of Repairs or Alterations--Answer when applicable............................................................................................... ....................................................... ''_--.--_---------_-'_--.---_-'---''--__-- Agccnmeuc: The undersigned agrees to install the aforedescri6ed Individual Sewage Disposal System in accordance with the provisions of THT�U 5of the State S place the system in operation until aCertificate ofCompliance � Signed... .... ^~-'—..."---..................... p-----Vate---'--- Aooicutioxz Approved By.......... ' ~ -__--_-------_____ _________._________ ~ ~ Date. Application Disapproved for the following reasons:................................................................................................................ -------'------''---'-------------''---------------`-'---'---------------------------------'---- Date Peroit No.-' �~ �J Issued....................................................... --- TOWN OF BAR STABLEov G t--f' e •L:OCATIO SEWAGE # ' VILLAGE`'l��'%y1 "SE R'S A OP Sr LOT (� h INSTALLER'S NAME & PHONE N SEPTIC TANK CAPACITY D� LEACHING FACILITY:(type) _(size) G NO. OF BEDROOMS PRIVATE WELL O UBLIC WATER BUILDER OR OWNER_ G�7 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED__ --2--6 .g . VARIANCE GRANTED: Yes No t/� _ S t .. � _ � �` i J .� � 1 75 FBx THE COMMONWEALTH OF MASSACHUSE77S BOAR® OF HEALTH .................OF.....6,.{ •'1 >1; 1 C................................ Application for Disposal Marks Tinuitnution frrmft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --• J..��.. ! -�.L I� :;........................................... .................................. \.1A.5......tA- L tion-Address or Lot No. -ooyl t . ......i n w = .... ._.......... :. ... .... 2 •-- Installer Address ype of Building Size Lot_A'a�•l..._......Sq. feet a Dwelling—No. of Bedrooms....-....................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) GL Other fixtures ...................... . .. Design Flow.._`+n1.!57............................gallons per person per day. Total daily flow........ ._...� ?.....•.--...............gallons. Septic Tank—Liquid capacityl�..gallons Length......... _......(.._.. Width................. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No..................... Diameter.._........_......_. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•---------------------- ------------------------- .............••... ..........._............................................................... 0 Description of Soil.............................. %_1 . zc r f? c:_a --------••-- U ----------------------------------- --------------- ------------------------------ •.............. ------------------------------------------------ .--------------------------- ••-•------- •-•--------------- W ....••--••••••••-•-•-----•-••••••-•-••-•--•-•----••---••••••-•••••••------••••••--••........---•••-•-••-•-••••......•-----•--••--•-••-... •----------------- -----------•------------------------ •... .... UNature of Repairs or Alterations—Answer when applicable............................................................................................... -•----------------------------•--............_....---------•----•---......-----------------...--------•---•-------------------•--•----........-------•-----•---------------......•-•-••-----•-----.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned urt r agrees not to place the system in operation until a Certificate of Compliance has;b n issued b e bo d o l - Signed.... • ... .... .... ...................... -! .... Date Application Approved By-•--•-•-•-v -- _. ::..r= .� y....................... Date Application Disapproved for the following reasons:.......................................................................................................... ..............•-•----•---•-•-•-••--•--------•-----•----------...-----------•--------------•-----......._.---...----------.........................................--••--••-----•--•--•-•••--•---------- Date Permit No. _ 12. -z- _.__ Issued...................... ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD fOF HEALTH /z.•::G../'.,. ......OF..........1..:-t.^................................................................. Trrfif i rab of THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••- 1 Installer at ... 7 }Ct. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........... :.... dated..............r.................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. -�..--'o L.& �---------------••-•---•-••-----•--. Inspector.............. ------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ��jj BOARD OF HEALTH r7 i �?•: :.:%.............OF.........{ ,............ .Dia 4 ��..__................................. ._ — No.... ........ �1� F>�..� .. ........... Disposal Works Tonstrudinn Viermu Permission is hereby granted............................... to Construct (\10 or Repair ( ) an Individual Sewage Disposal System atNo.........�r�' T S- ..... c::.,..........`..._.`-"- ......- ��/..-- .n ..,'---..-•--•..................•----•--------•---••-•-•--•--•-•----.......... Street c, 1 as shown on the application for Disposal Works Construction Permit Dated.......................................... ......---•------------------------------------------•---•---•-•---------•-•-••--•-----•--•••---•--....._ Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON v DESIGN DATA 10,3 . - �z SINGLE FAMILY - 3 BEDROOM I 700 NO GARBAGE DISPOSAL DAILY FLOW = 110 x 3 = 330 G.P,D. 1 '��°\ 201E \ SEPTIC TANK = 330 150% = 495 G.P.D. �6 .I ,I, 4° USE 1000 GAL. TANK Lie L�,T's �0 P20P DISPOSAL PIT - USE ( I ) 1,000 GAL. ,��I r 1 SSA I F SIDEWVALL AREA = 150 S.F. ,� d 150 S.F. x 2.5 = 375 G.P.D. .J/ BOTTOM AREA = 50 S.F. � Q p�P 50 S.F. -�% I.0 = 50 G.P.D. TOTAL_ DESIGN = 425 G.P°D. , TOTAL DAILY FLOW = 330 G.P.D. 3s + /o• _. ! P;.-i. PERCOLATION RATE : I" IN 2 MIN• OR LESS 1 rgaK "'°'�, ,, ° i / Eel TEST HOLE # F.G. F.G. = 7/' TOP FND.=.7z•a' oAi�C 77 P.V.C. ° /4" SCHED: 40 :10.00 INV. �9 7.. . 1000 GAL. INV. G8. DIST: INV. INV. - GAL. =° - 42'' �° ;EACH PIT 1 j BOX 0,3 SEPTIC a° WITH I' o TANK M _ . 3/4" TO INV. 68,9 INV.0, , SW SHED ° EL.�z.7 C'4�7�G-K1CouuTZAaZ-b�ALL ,ijsuITAN.c G-1ZAU PROFILE • ' tic- ;SNALLPC QC�(ovEDL�NE " � r 1; q' 4 �, r�F{:t t ,r? JVVECALE .. atEAu�►�J� Fac►��TY' as►lAcL:�� ,!T (AC�:D u 1TN U-P-AAN SAID q C,RA I Q.B' r�•i3 ^,r t7!.t/ ! G. ^ - +/ ty Filiil!\r J 'S,t rl�i F,,. r"•J �;' "I Accz,iu,A--7)c i�ii'f-►ri A. TIFIED PL 4/ T LOCATION M•4/u 7'6,1 s tft1/3 /y4S;S I CERTIFY THAT THE PROPOSED FOUNDATION SHOWN HEREON COMPLYS WITH SCALE l''_ 4-c' DATE 5- THE SIDELINE AND SE TBACK REQUIREMENTS OF THE TOWN OF PLAN REFERENCE i BARNSTABLE AND IS NOT LOCATED Lot- S, i ' WITHIN THE FLOODPLAIN. PL. 31C �Z6 PG 67I I { DATE e 5 �'g� G uJ ��- BAXTER B NYE' INC REGISTERED LAND SURVEYORS -' ! THIS PLAN IS NOT BASED ON AN I • 8 E ; , . INSTRUMENT SURVEY AND THE OFFSETS CIVIL ENGINEERS SHOWN SHOULD NOT BE USED TO - OSTERVILLE, MASS. , i DETERMINE LOT LINES: APPLICANT ;`j ; `