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HomeMy WebLinkAbout0760 RIVER ROAD - Health 760,River-Road Marstons Mills P fj A 044 007001 i� t t a' any:oo--oat Commonwealth of Massachusetts W Title 5 Official Inspection Form ,1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �7 760 River Road Property Address Anna Brigham Owner Owner's Name information is infor ti for Marstons Mills ✓ Ma 02648 2/6/2018 requipage. Cityr'rown State Zip Code Date of Inspection" Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information Sj /age filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. --��U Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b he Local Approving Authority 2/6/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ly VS Commonwealth of Massachusetts rz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 760 River Road Marstons Mills is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 3 500 gallon leaching chambers. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the!box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018. page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,..�� 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °y 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface'sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd !Sins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 't 760 River Road Property Address Anna Brigham Owner Owners Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap, present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M °af 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 4/11/2005 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron I ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: . et 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: 1500 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" 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? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Covers are on risers, water level even with outlet invert, tank structurally sound and not leaking. Outlet tee 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts N r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No mns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was video inspected and found in good condition with no rot, water level even with outlets with no sign of past hydraulic overloading. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): s.a.s. consists of 3 500 gallon leaching chambers . Leaching facility was located but not excavated, no signs of past failure, vegetation was normal. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately e_647'3 t5ins-3/13 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 760 River Road Property Address Anna Brigham Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/6/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOW-k'QF BARNSTABLE LOCATION A am � SEWAGE #�v��=A3 1 . VILLAGE f N)l k ,. ASSESSOR'S MAP & L0`166 Z 4'-7-d?J INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY' 6® LEACHING-FACILITY: (type) (size) ' b X33 NO.OF BEDROOMS �/o 6jv'� .. . at a BUILD EROR OWNER PERMIT DATE: I �� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 t ofA.le�hi fayc�ielity�),l�� Feet Furnished by, n.�1 1 1 �"" i �3-2 6-2,1p. �—�2,0a y& 6 C 647,3 616 TO�o BARNSTABLE t LOCATION SEWAGE # 2-d05"6 3 1 VILLAGE v ASSESSOR'S MAP & LOVSA 001 140I INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY 6 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 1 T q19 BUILDER OR OWNER I r 'k&G4 PERMITDATE: I"I�'®S. COMPLIANCE DATE: T 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 feetef leachin facility) Feet Furnished by � Sod-a?�l •A�` i JA No. S--b� THE COMMONWEALTH OF MASSACHUSETTS — FEE BOARD, OF HEALTH 4 OF APPLICATION FOR ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - [Complete System ❑Individual Components �uo y-a L� J�Bern �1 (&be Ian Location Owner's Name 64 Map/Parcel# Address Lot# T lephon # Installer's Name Designer's Name Address Address� Telephone# Telephone# Type of Building: Lot Size 'S'� t(WIS Sq­feeY Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min..Tequ`iired) S� gpd Calculated design flow gpd Design flow provided i_(Z) gpd Plan: Datq �2-"l O'i . Number of sheets ` Revision Date Title 4" - .o Description of S il(s)C 1 w tG`= Io&A, a A - Soil Evaluator Form No. Name of Soil Evaluator �t�/I,n.i c LL—, Date of Evaluation (�)'A 2• Q DESCRIPTION OF REPAIRS OR ALTERATIONS 7 01-74C, he and si n d a rees to i to the above described Individual Sewage Disposal System in accordance with the provisions of TIT 5 an fu ag s not pi a the system in#peration until a Certificate of Compliance has been issued by the Board of Health. Signed B Date Inspections ins �-3 FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 " No. �C) 5"�3 THE COMMONWEALTH OF MASSACHUSETTS.``_ FEE . l 60 ° �fBOARD OF HEALTH t km -"" , OF rlA/1 t_ , APPLICATION FOR DISPOSAL SYSTEM-CONSTRUCTION PERMIT 4. Application for a Permit to Construct (, Repair ( ) Upgrade ( ) Abandon ( �) omplete System ❑Individual Components &fN \ �1 �1'� ,,Loca�jI_ � �/� , Owner's Name. T L`i Map/Parcel# '1 - Address Lot# �r T lephon # Installer's Name Designer's Name t` Address Address Telephone# Telephone# Type of Building: Lot Size �'S�� alyis Sq-feef s Dwelling—No.of Bedrooms Q Garbage Grinder ( ) Other—Type of Building No.of persons t J Showers ( ), Cafeteria ( ) Other fixtures , Design Flow(min. equ red) gpd Calculated desi n flow ( gpd l, !Design flow provided � gpd f. Plan: Date IT- -04 Number of sheets A .R_(.Il,evision Date 1 I r Title �I AA rll f-t I aJ11 i . (�� zt. t!�o o • �t� n C• C E Description of Sloil(s)&_k�\q,aw..to``�7�4`' It)-gV1..tS&4 ?_4`'- y3L`' MXLl Soil Evaluator Form No. Name of Soil Evaluator . tit c! Date of Evaluation �S`1 DESCRIPTION OF REPAIRS OR ALTERATIONS lThe and �gn}d agdrees to i sl the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 an fu ag s not pl a the system in} peration until a Certificate of Compliance has been issued by the Board of Health. Signe D w Date Inspections l i FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 t No. V THE COMMONWEALTH OF MASSACHUSETTS FEE O U BOARD OF HEALTH CERTIFICATE OF COMPLIANCE I Description of Work: ❑ Individual Component(s) ®Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) .% by: 46 (►�,,�� 1(� two at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.BOOS dated / �/V,0 Approved Design Flow y�/(3 (gpd) Installer ('� t Designer: `�.o.r-hTq,tjog Inspector Date 14 The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. f FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 1 - i No. a s -•-O3 THE COMMONWEALTH OF MASSACHUSETTS FEE -- �+� '�D�V� BOARD OF HEALTH �f DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at -(d) t V o c )t as described in the application for Disposal System Construction Permit No. 0�0 S dated Provided: Construction shall be completed within three years of the date of this rm 1 conditions must be met. A Date Ik Board of Health I FORM 2 - DSCP DEP APPROVED FORM 5/96 I, FORM 1255 (REV 5/96) H&W HOBBSB WARREN PUBLISHERS- BOSTON i Town of Barnstable Regulatory Services �lA of 81�Rh5tXBLE * snxxsrABLE, MASS. Ma a Thomas F. Geiler, Director 9�A 059. ��. M5 APR 12 PM 12, o0 lFo �' Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601-- -�--t-3�VISIQ Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form Date: Designer: Cq404 21, �aac�s Ens trlea./c p Address: 900 raLen36 I c On was issued a permit to install a (date) (installer) septic system at%0 aw I►4k tS based on a design I drew, (a dress) dated 17— IZ`4 ✓ I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by - designer to-follow: r, �a OFRICHARD filq., nn NA, U BERTT"AND t� 29594 (Designer's Signature) p Here) PLEASE RETURN *' TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL-NOT BE ISSUED UNTIL°BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form Town of 8arnstable P# 010, C Department of Health,Safety,and Environmental Set-vices �THE Public Health Division Date (—o 367 Main Street,I lyannis MA 02601 BABNBTABM MAM rE Date Scheduled b' G Time /y��/�/� Fee Pd. Soil Suitability Assessment for Sewage Disposal. Perronned By: �-J .Sep n G" Witnessed By: )[X✓j W. 0, jF5- LOCATION & GENERAL INI+ORMATION Location Address �� 5�`,'o Owner's Name MaJrU-41 1, 1Q�' {�A`� Address Assessor's Map/Parcel: D 41 1 �Gl d(�rOe 1^ ` Engineer's Name Goe 4 NEW CONSTRUCTION REPAIR ✓ Telephone H �l'L Land Use Slopes(%) Surface Stones Distances from: Open Water Body 3 e B Possible Wet Area R Drinking Water Well n Drainage.Way ft Property Line fi Other" n SKETCH: (Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) OWL- 30 Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in I lole: Weeping from Pit Pace Estimated Seasonal I ligh Groundwater DETERMINATION FOR -SE EASONAL IIIGII WATER TABLE' Melhod Used:Depth__Ob_served standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment t1. Index Well N Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST bate /Y Time Observation I lole H Time at 9"Ae + ,f V Depth of Pere 2 ' ` Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed t/ Site Failed: Additional Testing Needed(Ye Original: Public health Division Observation Hole Data,To Be Completed on Back Copy: Applicant ` ' DEEP OBSERVATION BOLE LOG Hole Depth from Soil Ilorizon Soil Texture Soil Color 9'oil ~',I , Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Slones,I3oulderes. n i nc I 0 —/0 � 14- L04-1 K / /oto— ZS/ ,(� 404 r /0 y2 sd .N mod. DEEP OBSERVATION MOLE LOG Hole# Z- Depth from Soil I lorizon 1 Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,I3oulderes. Consistericy,O/o Qraycl) DEEP OBSERVATION HOLE LOG `` I-Tole # Depth from Soil I lorizon Soil Texturc Soil Color Soil Other Surface(hi.) (USDA) (Munsell) Mottling (Structure,Stones,lloulderes. Consistency.%Uravel) DEEP OBSERVATION HOLE LOG •Hole# Dep(h from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,S(ones,I3oulderes. onsistenc °o ravel Flood Insurance Rate Man: / Above 500 year flood boundary No_ Ycc v Within 500 year boundary No— Yes Within 100 year flood boundary No '� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y« If not,what is the depth of naturally occurring pervious material? Certification I certify that oil y 1'-5 (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required lramin , expertise and experience described in 310 CMR 15.017. / Signature Date • TOWN OF BARNSTABLE LOCATION VCr' "�\ J Sw*A:6-t#finsRe ri'or) VILLAGE ASSESSOR'S MAP&PARCELO�W-1 —00 1 'S NAME&PHONE NO.'=f%L� ® n1�q P�'rn SEPTIC TANK CAPACITY k 5-00 Q LEACHING FACILITY:(type) ble-uy btr% (size) NO.OF BEDROOMS Lq OWNER One ii PERMIT DATE: Cl@##tg E DATE:a,.SP. 3 I " 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 L_ 414`,1\•,'\F�f\1',J\','\ Water Service • ! J ? F f / f f ! r f • F f J F 1 ! f r f + { , f f / F I F f f 4 k 4 4+4 \+\ 4 4 4 \•\ 4 \ 4 4 4 \ \ 4 4 \ \ \ 4 \ \ \ \l\ 4• 4 4 \ \ • 1 J f f ! ? f f`': ? f f r ! / / J f fr ? 1f•/ ? , fF { FfJ ? 1F1F , ! / , Fff / / 46 16 36 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M a 760 River Road_ Property Address Elizabeth & Christian Oman___ Owner Owner's Name information is Marstons Mllls __ MA 02648 March 25, 2009 required for ------------ �—--- � State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the lab key to move your Patrick M. O'Connell_ cursor-do not Name of Inspector use the return key. Seeptic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills _ _ MA 02648 rerun CityrTown State Zip Code 508-428-1779 SI 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 16.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority March 25, 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 09-50 Oman.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page f of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road _— Property Address Elizabeth & Christian Oman _ Owner Owner's Name information is Marstons Mllls MA 02648 March 25, 2009 required for ------ every page. Citylrown 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 system shows no evidence of surcharge. 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 pipes) 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 09-50 Oman.doc-08106 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 760 River Road Property Address Elizabeth & Christian Oman Owner Owner's Name information is Marstons Mllls MA 02648 March 25, 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. 09-50 Oman.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 3 of 115 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �., 760 River Road Property Address Elizabeth & Christian Oman_ Owner Owner's Name information is required for Marstons Mllls MA 02648 March 25, 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 El ® 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. 09.50 Oman.doc•08/06 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 M 760 River Road Property Address Elizabeth &_Christian_Oman _ Owner Owner's Name information is required for Marstons Mllls MA 02648 March 25, 2009 _ 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 El El Area 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. 09-50 Oman.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 760 River Road__ _ Property Address Elizabeth & Christian Oman Owner Owner's Name information is Marstons Mllls MA 02648 March 25, 2009 required for — every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® 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)] 09-50 Oman.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Elizabeth & Christian Oman__ Owner Owner's Name information is required for Marstons Mills MA 02648 March 25, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 4 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): 09-50 Oman.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 760 River Road Property Address ----- -------- — Elizabeth & Christian Oman Owner Owner's Name information is Marstons Mllls ---- .- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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: Compliance date: 4/11/05 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-50 Oman.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 ,M 760 River Road _ Property Address Elizabeth & Christian Oman Owner Owner's Name information is Marstons Mllls MA 02648 March 25, 2009 required for -----------------._....------------------ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 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): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of 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 31" 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 09-50 Oman.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Elizabeth_& Christian Oman Owner Owner's Name----- ------ --- — information is required for Marstons Mllls MA 02648 March 25, 2009 _._. every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in need of pumping at this time, tees were found intact and clear with liquid level at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of co-)struction: ❑ 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.): --------- _- or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below crade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): I 09-50 Oman.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Elizabeth & Christian_Oman_ Owner Owner's Name information is required for Marstons Mllls MA _02648 March 25, 2009 --- _...._..._...-._._. -------_...--- -------------- every;page. City/Town 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 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 all outlet pipes. PumpChamber (locate on site Ian): p Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-50 Oman.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 a 760 River Road Property Address Elizabeth_& Christian_ Oman_ Owner Owner's Name information is Marstons Mllls MA 02648 March 25, 2009 required for ---.-----____..----------_-------._---- every page. Cityrrown 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: ® leaching chambers number: Three 500 gal drywelis. ❑ 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 chambers show no evidence of surcharge or hydraulic failure. Soils and stone surrounding SAS were probed and found no signs of saturation. 09.50 Oman.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Elizabeth & Christian Oman Owner Owner's Name information is required for Marstons Mills MA 02648 March 25, 2009 _- -._ every page. CityrTown 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.): I 09-50 Oman.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form JJ� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a >� 760 River Road _ _..--- ----- - ------ Property Address ..-. Elizabeth & Christian Oman Owner Owner s Name information is required for Marstons_ Mllls MA 02648 March 25 2009 _. . . every page. City,Town 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. Water Service . . . . . . . .. . % \J ` \ 46 '`• ,f 4f, V 16 36 n :j 1 II, Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 760 River Road Property Address Elizabeth & Christian Oman Owner Owner's Name information is Marstons Mllls MA 02648 March 25, 2009 required for -----.--.— every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated death 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: You must describe how you established the high ground water elevation: Pond on opposite side of road is considerably lower than bottom of SAS. 09-50 Oman doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1 _ � �- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP PARCEL LOT . . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 760 River Road Marstons Mills MA 02648 Owner's Name: Maureen McPhee and Karen Maier Owner's Address: PO Box 506 Marstons Mills MA 02648 Date of 1 nspection: January 22,2004 4649 Name of Inspector: PATRICK M. O'CONNELLgZ� Company Name: SEPTIC INSPECTION SERVICES CO. �� Mailing; Address: 189 CAMMETT ROAD 1 TNp SST MARSTONS MILLS MA 02648 FjO�� - Teleph 3iie Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below i i :rue,accurate and complete as of the time of the inspection. The inspection was performed based on my training F.nd 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: `���1Ut11I111l�1��i OF _X_ Passes `�� •,.. r'., s Conditionally Passes Needs Further Evaluation by the Local Approving Authority : P TRH Fails !' 0 C fit Inspector's Signatures Date: _1/22/04_ �' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeafY ,S INSPEG� DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000«tll Ittttt gpd or ,gr.-ater,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. Notes and Comments: Older cesspool with overflow show no signs of failure,has had no use for two years and limited use for a number of years prior. ""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 conditimis of use. Title 5 nspection Form 6/15/2000 page 1 f Page 2 J I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 760 River Road,Marstons Mills Owner: Maureen McPhee and Karen Maier Date of Inspection:January 22,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: Core 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 lies,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain '"lie 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.rank 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 indicati n;;that the tank is less than 20 years old is available. ND exf loin: Cbservation 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 exf lain: rlie system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass ins p.-ction if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND exf Is in: Page 3 )°1 I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 760 River Road,Marstons Mills Owner: Maureen McPhee and Karen Maier Date oi'1 nspection: January 22,2004 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 sirstem 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. _ 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: Page 4 :if 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 760 River Road Owner: Maureen McPhee and Karen Maier Date of'Inspection: January 22,2004 D. Sy►l em Failure Criteria applicable to all systems: You mn;it indicate"yes"or"no"to each of the following for all inspections: Yes No X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X:_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ^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: To be considered a large system the system must serve 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 ':he 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. A Page 5 J 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 760 River Road,Marstons Mills Owner: Maureen McPhee and Karen Maier Date of Inspection: January 22,2004 Check ifthe following have been done.You must indicate"yes"or"no"as to each of the following: Yes Na _ _X— Pumping information was provided by the owner,occupant,or Board of Health _ _;t:_ Were any of the system components pumped out in the previous two weeks? _ _;t:_ 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? _:t:_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ _ Was the site inspected for signs of break out? _X_ _ _ Were all system components,excluding the SAS,located on site? _X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the conditit)-n of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper mainteri,urce of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes n c — _;t_ Existing information. For example,a plan at the Board of Health. _X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 If 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 760 River Road,Marstons Mills Owner: Maureen McPhee and Karen Maier Date of Inspection: January 22,2004 FLOW CONDITIONS RESIDI!:NTIAL Numbe-of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIG`t flow based on 3 10 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Numbe-of current residents:0 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): Seasonu..use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)):' 2002—0 gal.2003—0 gal. Sump ptanp(yes or no): No Last da1v of occupancy: Two years COMM ERCIALANDUSTRIAL Type of-,stablishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): _ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-san:tary waste discharged to the Title 5 system(yes or no): Water rn,-ter readings,if available: Last da,:e of occupancy/use: OTHE R(describe): GENERAL INFORMATION Pumping Records: None Source of information: - Was sy:,t.-m pumped as part of the inspection(yes or no): No If yes,vc lume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Sing a cesspool _X_Ove:,flow cesspool _Pri vy Sharud 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 obtaine i from system owner) —Tighi tank _Attach a copy of the DEP approval Other(describe): Approx intate age of all components,date installed(if known)and source of information: 1950's Were sewage odors detected when arriving at the site(yes or no): No Page 7 )f l l 113FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 760 River Road,Marstons Mills Owner: Maureen McPhee and Karen Maier Date of Inspection: January 22,2004 BUILE-ING SEWER: X (locate on site plan) Depth below grade: 6" Materk is of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: 20' Commt nts(on condition of joints, venting,evidence of leakage,etc.): No evidence of leaks. SEPTIbC TANK: No (locate on site plan) Depth below grade:Material of construction: concrete_metal_fiberglass_polyethylene _otht:r(explain) If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or:no):_(attach a copy of certific,te) Dimens ions:- Sludge iepth: - Distanc-.from top of sludge to bottom of outlet tee or baffle:- Scum tl dckness: - Distanc;from top of scum to top of outlet tee or baffle: - Distant:from bottom of scum to bottom of outlet tee or baffle:- How m ere dimensions determined: STICK WITH HINGE FLAP. Comme ats(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate:d to outlet invert,evidence of leakage,etc.): GREA:-'.E TRAP: No (locate on site plan) Depth b-.low grade:_ Materia. of construction:—concrete_metal_fiberglass_polyethylene_other (explain): ): Dimensions; Scum thickness: Distant: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 ast pumping: Comm- nts(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relatr,i to outlet invert,evidence of leakage, etc.): 17 it Page 8 3f 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 760 River Road,Marstons Mills Owner:Maureen McPhee and Karen Maier Date of Inspection: January 22,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Materiel of construction: concrete metal fiberglass polyethylene__other(explain): Dimew ions: Capacit y: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Commt nts(condition of alarm and float switches,etc.): DISTRIBUTION BOX: . No (if present must be opened) (locate on site plan) Depth ff liquid level above outlet invert: - Commt nts(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.): PUMP CHAMBER: No (locate on site plan) Pumps n working order(yes or no): Alarms in working order(yes or no): Commt ats(note condition of pump chamber,condition of pumps and appurtenances,etc.): o Page 9 )f i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 760 River Road,Marstons Mills Owner: Maureen McPhee and Karen Maier Date of Inspection: January 22,2004 SOIL iiBSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type le aching pits,number: leaching chambers,number: —leaching galleries,number: leaching trenches,number,length- leaching fields,number,dimensions: _X_a verflow cesspool,number: One 6x6 block pit it novative/alternative system Type/name of technology: Comm(nts(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Empty at time of inspection No evidence of breakout or high stains. I CESSPOOLS: X (cesspool must be pumped as part of inspection) (locate on site plan) Numbe and configuration: One with overflow Depth- top of liquid to inlet invert: 6' Depth of solids layer: 0" Depth of scum layer: 0" Dimen,ions of cesspool: 6'dia.x 6'deep Materh is of construction: Block Indication of groundwater inflow(yes or no): No Commf nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Blocks are intact,cesspool empty at time of inspection. PRIV1: No (locate on site plan) Materiels of construction: Dimew ions: Depth c,f solids: Comme nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I • Page H of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:760 River Road,Marstons Mills Owner. Maureen McPhee and Karen Maier Date of Inspection: January 22,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchrr arks. Locate all wells within 100 feet.Locate where public water supply enters the building. River Road I Page Y of l l '13FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propel ty Address: 760 River Road,Marstons Mills Owne►: Maureen McPhee and Karen Maier Date o f inspection: January 22,2004 SITE li XAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 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: _X_Cibserved site(abutting property/observation hole within 150 feet of SAS) C necked with local Board of Health-explain: C.iecked with local excavators,installers-(attach documentation) A.-cessed USGS database-explain: You must describe how you established the high ground water elevation: Bottom of Cesspools considerably higher than pond on opposite side of road. B 4 20'-0" 4'-0" ANDERSEN ANDERSEN ANDERSEN FWG 506E FWG 5068 FWG 5068 AN ERSEN NOTE: H F114 2 6065 ANDERS THESE DRAWINGS AS SHOWN ARE FOR ILLUSTRATIVE PURPOSES ONLY. FWG 60 CONTRACTOR IS TO SITE VERIFY ALL EXISTING VS. PROPOSED CONDITIONS PRIOR TO AND DURING r 3 SEASONS CONSTRUCTION AND TO MAKE ALTERATIONS AND/OR ADJUSTMENTS TO WORK AS IT PROGRESSES TO PROVIDE FOR A COMPLETED PROJECT IN COMPLIANCE WITH DESIGN co o AERSEN6° 6. PARAMETERS AND MINIMUM STANDARDS SET FORTH IN MA STATE BUILDING CODE AND , 6068 APPLICABLE TOWN ORDINANCES. CONTRACTOR TO VERIFY ALL DIMENSIONS 20'-O° F ANDERSEN � PRIOR TO BEGINNINGG OF OF CONSTRUCTION. I4'-On FWG 6 6x6 P.T. POST WRAP w11- TRIM �- ® FmA z rz '•a I ANDERSEN FWG806B y 6'-1• 1 q° cA I L 406B DINING O O I LIVING RM. ANDERSEN FWG806 ce 281_0n V 4n C, a O i6i 3068 v 3'_4° z I--1 � z r m � FAMILY ROOM r z ROOF\ WINDOW LOCATIONS O UP ® DEG DECK w 0 A 5068 G _ TO BE DETERMINED A w oi W � O 1 KITCHEN 1 2468 2668 - COVERED m '-0° 4 O" 7'-2° 7'-2n 4' I " '-O I W PORCH i DECKING O O OB f---- -------- --J _6• TO BE DETERMINE tt I -�`�- B Q LIN M. SEDRM. o 0 O OO CAE -----1 - ANDERSEN 6 Q C. 1 w t3'-B° _ FWN316B ANDERSEN (ly' '�q FWN3168 O M. BATH 2668 � � BEDROOM , � .�'_qn 2668 u, m o [1-) B-Bn m © 5068 t01-4n �1i CID A d' iV 668 _ n O O .�.� 2668 (� as _ -- z pq 2668 0 r-6° O S�_0. iv GL. 26•.^. O Z 20'-O° 2B'-O° B�_0° � m P4 �. 5068 ® AA FIRST FLOOR PLAN 7 DN. ' SCALE:,/4•=,'-0'=1'-0• ___ __ t _ _________ 2 ------------- 246 _ _----_-__- INDICATES NEW WALL CONSTRUCTION O a' BEDROOM c------- INDICATES WALLS TO BE REMOVED O ,L3 O a• O _ 2 O o _ i ® BATH - ® n DATE oe/oa/oa REVISIONS AREA CALCULATIONS - e 0 IST FLOOR LIVING SPACE .1,280 S.F. DRAWN BY 3 SEASONS RM. 236 S.F. 9'-8° 4'-II° 5'-5• g'_q" 4'-7° 3'-8° 2ND FLOOR LIVING SPACE a q52 S.F. DRAWING NO 0 �/ �Q� �� A) SECOND FLOOR PLAN Al 4 114" CROWN MOULD ON Ix1O RAKE BD ASPHALT SHINGLES O G N 1 O I co 0 ALUMN. GUTTERS ON IxB FASCIA BDS. IxIO FRIEZE BDS 36' RAILING WOVEN CORNERS ® F�lz r� Ix6 CORNER BDS. W.C. SHINGLES (5 V2" EXPOSURE) a A rd r: cli nil 10"x10' COLUMN-TYP. L1J r FRONT ELEVATION A a � 0 12 t2 [� r � Q.i 6 2 O O E• a ow z oZ H A I I DATE ae/oa/oa REVISIONS rZREAR ELEVATION DRAWN BY DRAWING NO. A2 0 H m ql- n o 12 - S I- E Q HELD ® ® PEAz � z a N z _:I G SIDE ELEVATION Z x z W a A a b� 12 a lot o w 12 (/] z A � 9 ® z z porF h a DATE 0s/os/o4 REws10NS CLEFT SIDE ELEVATION DRAWN BY DRAWING NO. A3 1` 20'-0" 4--0- CONTINUOUS 2x6 P.T_ SILL PLATE/SILL INSUL. w/1/2' VIA GALV. A.B. ®61-0' O.G. MAX CONTINUOUS I Wx4-0' GONG. WALL I I ON 16'xl0' CONC. FTG. I I u o PROVIDE (2) CELLAR VENTS O I I DRIL It GROUT = c I a I I #4 DOWELS 0 12' O.G. - o I I TYP - 12" DIA. CONC. N x SONOTUSE ON "p I n I 24'x24'xl2' CONC. FTG. m o o r n F FOR A/S TO/OPENING L J NEW CRAWL P. P.T. 2x8 0 I6' 0 C. O � a EXISTING FND. r o LJ m n 6 c z F m GUT OUT 36" OPENING A w FOR ACCESS TO/ NEW CRAWL SP. I I I � N I I PROVIDE (2) CELLAR VENTS ® I I O CONTINUOUS I I r' ZI 0' WxW-O' CONC. WALL I I - ON I6"xIO" CONC. FTC. L_J O I L - -- - -- - --- - --- --� I U2 — — — — — — —— ——— ——— — — —— Z A d O O E-+ p� P: 2B'-O" 7'-2" z y d xxz z o z � FOUNDATION PLAN scnlEva•=r-0-=ram p � � co E-� WINDOW SCHEDULE a SYM. MANUFACTURER'S UNIT ROUGH OPENING REMARKS A ANDERSEN TW2032 2'-2 1/8"x3'-4 7/8" B ANDERSEN TW2442 2'-6 1/8"x4'-4 7/8" C C235 4'-0 1/2"x3'-5 3/8" D ANDERSEN TW24210 1'-10 1/8"x3'-0 7/8" E ANDERSEN A21 2'-0 5/8"x2'-0 5/8" IDATE 06104 04 REVISIONS NOTES: I. ALL ANDERSON WINDOWS 4 DOORS TO BE 200 SERIES-WHITE 2. ALL ANDERSON WINDOWS TO HAVE SNAP IN VINYL GRILLES, DRAWN 8Y SEE ELEVATIONS FOR GRILLE PATTERNS. 3. PROVIDE INSECT SCREENS DRAWING NO. 4. HARDWARE TO BE DETERMINED BY OWNER A4 } TYPICAL ROOF CONSTRUCTION CON'T RIDGE VENT ASPHALT SHINGLES ON - BUILT-OVER ROOF 150 BUILDING FELT ON 2x12 RIDGE 8D. 1/2'Cox PLYND. 2x10 RAFTERS O IV 0.4 w/ 12 SIMPSON 142.6 CLIPS O IB•O.C. - 9'(R-30)FIBFRGLl49 BATT IOt KRAPT FACED INSUL. ., 12 / / 2x0 I 16'O.G. \ \ O / / \ O / \ w/ALUM ACUTTTTERS LI j / \ Ix SOFFIT w/ 2.B 0 16'O.C. CON'T VINn TYPICAL WALL COTISTRUCTIOa 2x4 SLEEPERS(TAPERED)TO SLOPE SOFFIT VENT W-C.W-0NGLES B'EXPOSURE e/4'T!G PLYWOOD co / - TYVEK HOUSE~ RUBBER ROOF MEMBRANE 10 U �� 1/2.CDX PLYWOOD PAN PLASH 2x4 SLEEPERS 2x4 STUDS O 16'O.G. DECKING �--�- a 11V RTi VNFACED FIBERGLASS Ey GATT INSULATION qqq \ E+ W2.G-W.B.. [ 1 TYP.2.d FLOOR CONSTRUCTION L� 5/4'TM PLYWD 5UBFLO0R ® F�l Z GLUED!NAILED OVER 1 3 � 2x10 O O.4 FLUSH ME I x 9 STRAPPING AT 16°O.G. y�-/ f � 1/2'G.WB. TYPICAL WALL CONSTRUCTION Z 1/2•COX PLYWOOD t- 2.4 STUDS O 16'D.C. TYP_i5T F.me CONSTRI-TION TYP-IST FLOOR CONSTRUCTION B TT NSREI LATIONUNFACED FIBERGLASS GATT INSULATION ^ 9/4'T!G PLYWD SUBFLOOR 3/4'T t G PLYND SUSFLOOR 1/2'G.W.B-FTD. W GLUED t NAILED OVER GLUED t NAILED OVER - GLUE•If.'O.C. 11 GLUED TNAI•I6'O.C. 6'(RI9)FIBERGLASS BATT INSULATION 61(R19)FIBERGLASS BATT INSULATI O 1` FOUNDATON: m BITUMINOUS DAMFPROOFING O2 -111€ CRAWL SP.FLOOR. ON W CONS -III 3 I/2'GONG-SLAB OVER 1111= FOUNDATION WALL w/ CRAWL 5P.FIDOR. 1--4 6 MIL POLY VAPOR BARRIER - ON 161xI0°DEEP 3 1/2'CONC.SLAB OVER EQUNDATION. ON W COMPACTED GRAVEL KEYED CONC.FOOTING Z i• b MIL POLY VAPOR BARRIER gITUMNOUS DAMPPROOFING ON 6'COMPACTED GRAVEL ON B CONS FOUNDATION WALL w/ ON I6'x10'DEEP 1"1 X z KEYED CONC.FOOTING U] Eq A CROSS SECTION pq A a CROSS SECTION scALeara•=r-o•=nv 12 5 2x8 o 16'o.c. r O Let 2-1 3/4'x9 1/4'LVL {. U A Ix6 PVC TtG BEAD HD- E O ON 2.6 O JV O.C. 6°x6'P-T-POST l WRAP w/tx TRIM-PAINTED y Ri ma TYPICAL _ 0 w 7 Ix6 COMP051TE DECKING ON - ,W Ic�yy - P.T.2x5 0 IV O.C. `ay FY y \ Z 2-P.T,2xs GIRT- Qi 0 12'VIA.CON E- SONOTUBE ON I-I 24'x24'x12'CONC.FTG. NOTE: USE SIMPSON TIES 14 AS REO'D {' CROSS SECTION DATE 06/0 a/04 REVISIONS • DRAWN BY + DRAWING NO. A5 SYSTEM PROFILE TOP OF NOT TO SCALE FOUNDATION FINISH GRADE FINISH GRADE OVER FINISH GRADE OVER EL. 112.4 EL. 111.5 • , SEPTIC TANK 111.3 DISTRIBUTION BOX 110.0 FINISH GRADE OVER TRENCHES 110.0 RISERS TO 6" i 7 F FIDII H GRAD , PRECAST CONCRETE 971., _�,. 500 GALLON DRYWELLS 3°MIN. °' RISERS TO 6" H-10 REINFORCED LOADING :��=_;01vtIN.SLOPE 1% OF FINISH GRADE OUTLET PIPE(S) LEVEL 13- FOR 2' MIN.1% SLOPE TRENCH LENGTH - 33'-6" 6" ~ MIN.SLOPE 1% o - o MIN. BEYOND 1 11vi >_ - DRYWELL LENGTH - 8-6 13"MIN. 14" = J 109.20 109.00 f MIN. b SUNII' o' PVC OR CAST IRON TEE 108.75 i' 1 10 1 - .`v ,. - • ` ` 108.18 ,. M�� ...I O:` k.�S ,i' 1, 11 OOt1 /.• 1 / '1:.. 1 �. GAS BAFFLE 6 'b �blr�, �Q; =6 DISTRIBUTION BOX 106.00 ;'�� or • •�, :, ` : •;,' ;:_ d '; MINIMUM INSIDE DIMENSION 12" " EL.104.0 ., 3/4 - 1-1/2 DOUBLE 11 „ - :p �500 GALLON ,A• 11 3/4 - 1-1 2 DOUBLE _ OUTLET INVERTS 2 BELOW INLET INVERT WASHED CRUSHED 4' �� PRECAST CONCRETE '� MINIMUM CONCRETE WALL THICKNESS 2" STONE 7 5 WASHED CRUSHED 1.Z • : 0 BSMT.FLR. o:: =;� `y H-1 O REINFORCED v INSTALL ON COMPACTED LEVEL BASE STONE NOTE: EXCAVATE TO =C=STRATUM IN ORDER TO ELEV.105.0 �6 q - . EL.96.5 BOTTOM OF TH#2 . J REMOVE ALL =A=& =B= IMPERVIOUS MATERIAL • ,, 1 ' WITHIN 5 OF THE SAS. REPLACE WITH CLEAN, TRENCH SECTION r •!. r.•� ,. .wry• ., ,_,, r-,� i •1e 1/ ,..,•,l 1 - r 1 P 11 c'' 4 v. r :1 0,o i r. or.• ,, cr ,'�o� ;�� of..,,� , ,oL ,�,,o , ,or f ii r. :1 ^t CLAY-FREE SAND 1 u ; � J3 0 CMR 15.255j SEPTIC TANK t , INSTALL ON COMPACTED LEVEL BASE 4 1 w Y - 9" MIN. • {k ,. f o ,,' +'; u 4" DIAM. 36" MAX. 3" PEASTONE 41 W. fo r off- 'or 3/4"- 1-1/2" DOUBLE 5'-211 WASHED CRUSHED : ;. STONE - s% RI TRENCH WIDTH / 13'- 211 '; I I- �� � a I�UMQrR OF TRENCHES 1 r NUMBER OF DRYWELLS 3 NOTE: EXCAVATE TO = RATUM IN ORDER;TO REMQ'�E ALL =A= &;B= IMP S MATERIAL _ .. .. a ::,. ,,, :; "p•u+4rtum.-y...►r.r r.o..0 w.ar,►�e."n.o-nm DE3SERVATI01\1 rn T UWI'THIN 5'OF THE SAS\REPLACE WI {{ CLAY-FREE SAND [31 0 0 R 15.255] P-10,749 ' ;»' - - s -3, ,o,ERCOLATION RATE: < 2 MIN./IN , 72w ' W- se - ^'��` _� 24„ WITNESSED BY: D.STANTON S1071, E GENERAL NOTES: BARNS. BOARD OF HEALTH., 1. ELEVATIONS SHOWN ARE BASED ON ASSUMED DATE: AUG.18,2004 ,1 ► ?,� 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON "' TH`#1 EL.K9.5 " TH#2 EL.108.5 DESIGN DATA OR SCHEDULE 40 PVC. 0 0 000 3. HEALTH AGENT/CAPE & ISLANDS ENGINEERING =A- LOAM - 108 110 FILL MUST BE NOTIFIED WHEN CONSTRUCTION IS 10 YR 2/2 #1 10, COMPLETE PRIOR TO BACKFILLING. 1011 60" NUMBER OF BEDROOMS 4 2871, 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED GARBAGE DISPOSAL NO ' ' s BY CAPE & ISLANDS ENGINEERING AND THE BOARD =B= LOAMY SAND =6= LOAMY SAND DAILY FLOW 440 GPD. i � OF HEALTH. 10YR 5/6 10YR 5/4 SEPTIC TANK REQUIRED 1500 GAL. 0 E XIS 5. MATERIALS AND INSTALLATION SHALL BE IN 4BD S 2411 8411 SEPTIC TANK PROVIDED 1500 GAL. ' COMPLIANCE WITH THE STATE SANITARY CODE ' ; 1�i• #�2 E. 19 [TITLE VI AND LOCAL APPLICABLE RULES AND „ PERC.TEST LEACHING REQUIRED 440 GPD. c 2845, -------------------- 6$ �`' REGULATIONS. EL.106.0 6. NORTH ARROW IS FROM RECORD PLANS AND IS SOIL ABSORPTION SYSTEM CALCULATIONS: \ NOT INTENDED FOR SOLAR ENERGY PURPOSES. =C= MEDIUM SAND =C=MEDIUM SAND - 7. WATER SUPPLY: MUNICIPAL WATER SYSTEM. 10YR 7/4 10YR 7/4 SIDEWALL AREA= 186 SF. 10 8. FLOOD ZONE C [NON-HAZARD] 186 SF. X .74 G/SF. = 137 GPD. f BOTTOM AREA = 441 S . NO GROUNDWATER 441 SF. X 0.74 G/SF. = 326 GPD. LEGEND I32° NO GROUNDWATER 14411 EL.96.5 LEACHING PROVIDED = 463 GPD. 7�-' ---- 52 PROPOSED CONTOUR - HSE.NO.760 SINGLE FAMILY RESIDENCE ---•52--- EXISTING CONTOUR .2.51 ACRES , '` PROPOSED SEWAGE DISPOSAL SYSTEM OBSERVATION PIT �Z9 of �r^ PREPARED FOR ❑ DISTRIBUTION BOX DAVID STEVEN GMTRELIS C. CHARLES -1 S A -.N 1CK1 0 0 0 28U85 , HSE.NO. 760 RIVER ROAD SEPTIC TANK t F�, o "STONS MZLLS,MASS. SOIL ABSORPTION SYSTEM a� L c S 85°30'23"W r ,,,•,�,, PLAN N0. 120904 SCALE: AS NOTED 200.08' I�sERVE RESERVE AREA �, ���N OF At'�ss9� FILE NO. 269MA DATE: DEC.12,2004 RICHARa �u, SEPTIC FILE NO. 75 PCS FILE: riverrd760 22.26 PIPE INVERT ELEVATION RERTRAND 29834 z z z �rI;sTEF�° . Q CAPE&ISLANDS ENGINEERING 0 0 0 800 FALMOUTH ROAD SUITE 301 C PLOT PLAN 44 7-1 760 5 5 5 i � vh��F3 � ' MASHPEE,MA 02649 (508)477-7272 SCALE: V =30' MAP SEC PCL LOT HSE ' I I I