HomeMy WebLinkAbout0972 RIVER ROAD - Health 972 RIV-ER ROAD, NARSTONS /TILLS �
,4= 045-010. 001
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$H0.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL, 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE: 7 IJ� Fill in please:
APPLICANT'S YOUR NAME/S: '
('fuwf Ir;pl:ri i 'G: 1 ,c r„ B .r
€,3 J;icm,,INde.� �'� !� ,��a�E USINESS YOUR HOME ADDRESS: 6�707 ��
tv PF1Ct�'a'.6�('.r!u�F}�l?FY!(I'�B rt �i1`}.•'s'''„-`�` /"/6d- /�e� 7
04
TELEPHONE # Home Telephone Number ScsS? 5,�9 Yvo
j' � 4 eln(�lll�init'•:9r�'�.f'��l�r� /I'�� I
_
NAME OF CORPORATION: SS o2�/ii/
NAME OF NEW BUSINESS TYPE OF BUSINESS
IS THIS A HOME OCCUPATION?
_YES NO / /
ADDRESS OF BUSINESS 9ZZ R.'v�.- /� �.-� /,, j ^-,Z/5 MAP/PARCEL NUMBER t�`t (6 -66 1 (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you-may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rol. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COM SSIO ER'S OFFICE
This individu I he e i� f a y p rmit requirements that pertain to this type of business.
MUST COMPLY WITH HOME OCCUPATION
ut on S gnatu * RULES AND REGULATIONS. FAILURE TO
OMMENT P `/ MAY RESULT IN FINES.
6
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2. BOARD DHEALTH
This individual has been i ormed of the,p5�nit re -ui ments that pertain to this type of business.
a z Signature - MUST COMPLY WITH ALL
COMMENTS: HAZARDOUS MATERIALS REGULATIONS
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business..
Authorized Signature**
COMMENTS:
TOWN OF BARNSTABLE Dater //x/
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUS INESS: 4 Lee �o,,a e,1';I �lanIn.cs
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: g.9��,«ram � ,,,,,,,;//S `,�,y yp TOTAL AMOUNT.
TELEPHONE NUMBER:
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: s MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/ / RRECOMME/NDATIOeNS::/ / Fire District:
/
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts(Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
Any other products with "poison" labels
❑ NEW ❑ USED (including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(pleased/ �,,/
Metal polishes C A,
n
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
��. (dry cleaners)
I
Other cleaning solvents
Bug and tar removers
Windshield wash Dz,
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Sign `ture Staff's Initials
TOWN OF BARNSTABLE
LOCATION 9 7 A IQTV��� I�n d}�SEWAGE# a 6 J q aF 4
VILLAGE ,A '�j�� ml ASSESSOR'S MAP&PARCEL ®'I
INSTALLER'S NAME&PHONE NO. 2goo
SEPTIC TANK CAPACITY -e-X t S T(^!cJ
LEACHING FACILITY: (type)�hridk§S' ?YJAdnLS (size)
NO.OF BEDROOMS 3
OWNER �o 4PERMIT DATE: �'1�'j y COMPLIANCE DATE:
_ h Separation Distance Between the: o
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility U Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
,site or within 200 feet of leaching facility) jE Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Aff Feet
a
FURNISHED BY
1 3
a
,5 l
9 17ol ot
No. — C�� Fee ���� �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYication for Disposal *pstem Construction 3permit
Application for a Permit to Construct( ) Repair 06 Upgrade( ) Abandon( ) ❑Complete System 9 Individual Components
Location Address or Lot NoR7L Pb vte- M M Owner's Name,Address,and Tel.No.
5 c ff v�^ew�a,S
Assessor's Map/Parcel s-- jo 5 -
Installer-'�s Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�jrQ F EII�;S Oo 2�igh# Eked MAc(A^CS COA54 t:?r"�9 9f 27gZ-o9l
t3o bbgSAyt�wicG, �z51, I%�'��-Zgoo goxtt*2 C, Ayk4_ LK VZ537
Type of Buflding: ?-9 f—13(- " I? //C
Dwelling No.of Bedrooms —3 �^ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building '�I/Lc4 JZ F Ii7 4 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided 31 f s- gpd
Plan Date -7— 3 O a—( Number of sheets Revision Date 004(Q
Title
Size of Septic Tank 4X[ 3 71 M r, 1600 Type of S.A.S. e t/t c-
Description of Soil 'qf
Nature of Repairs or Alterations(Answer when applicable) 12 L(h T 5
vA fW z S !-as fvve^the S 7•P3 x 3o k 1o,7 i
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ealth. Q
Si d Date
Application Approved by Date V/ '
Application Disapproved Date
for the following reasons
Permit No. ��— C�d Date Issued O l8 zo)
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,Yes `'
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplitation for i# osar 6pstet 64�u>ction permit 1
Application for a Permit to Construct( ) Repair K Upgrade( )F Abandon( ) ❑Complete System M Individual Components
Location Address or Lot No.Q 72 )�I v 4e 90,4D AA M Owner's Name,Address,and Tel.No.
I Sc vff k^-[N-e0,5
Assessor's Map/Parcel q - Ic, -5-A.
VK.-
Installer's Name,Address,and Tel.No,
Designer's Name,Address,and Tel.No.
j✓Q'1� !(�'S �tJoN2.lQcr��nf xc� /v1Attnnes C,_,n5�.tr��3 5�s 27yZ09I 5r.
13ox 669S�clwtcl., oZSl�3 W-2900 Bvy, iif2 C- j&nc+wj« 0253? -
Type of Building: y-,�3,P - �,�//
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building s;Aat i 2 (7AM 1 wJ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33 D gpd Design flow provided 3Y S` gpd
Plan Date -7- 3 U —t { Number of sheets `Revision Date n Ott
Title `Y�
Size of Septic Tank PX a )7 !G,/U �600 Type of S.A.S. 547)" le S S -t -ell c l--p-S
f D'eseription of Soil S-e,2 )0(.A^
Nature of Repairs or Alterations(Answer when applicable) PX0(Ac e Fc4 o (e 'ecj c,.C^ D 17 S
wtk zShm- IISS fwedeS ZJ31Yok /v.7s-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ealth. q
k Si d �` Date
Application Approved by Date ?W)/y
Application Disapproved Date
for the following reasons l
k Permit No. 701 L4- 13 Date Issued
--------------------- - - - ---------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(,K Upgraded( )
Abandoned( )by (C G( (I S f D v/12 K (C�Ll-4L)C C U,44 l G/1
n 'n _ a
at vl Z p ,/e/ I v!,�A has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.�i/ �- dated �I R { y
Installer ✓e-f E 7 s Designer MALI ones (UAS yl-V,nCt
#bedrooms Approved design flow�^� � and
The issuance of this permit shall not be construed as a guarantee that the system wil n I n as d signed.
Date 1 cT'D i Inspector
--------------------- -- --------------------------- ----------------------------1l---/--,----------
Fee�IV(/No. - U G _ J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposar *pstrm Construction 3permit
Permission is hereby granted to Construct( ) Repair(�() Upgrade( ) Abandon( )
System located at 1712- R( V 8 Q R OiA o
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit
Date_ �����I y Approved by �-
Toyvn oll Barnstable
Regulatory Services
OF 1HE�p�
do Richard V. Scali,Interim Director
., ,CAB Public Health Division
MASS.9� Thomas McKean, Director
ATEDM°�� 200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Homeowner Certification Form for Alternative Systems
Property Address: �7
Assessor's Map\Parcel:
Property Owners Name: SCU M �-lC 5
In accordance with Massachusetts DEP alternative system approval letters, the following certification
information is required by the Owner of record. The Owner of record must place an "x" in the
applicable box next to each line certifying the information.
Yes N\A
❑ I have been provided a copy of the Title 5 I/A technology Approval letters.
(16 page Standard Conditions letter and the specific technology letter)
❑ �I have been provided with the Owner's Manual
❑ I have been provided with the Operation and Mairr.enance Manual
❑ 2"For Systems installed under a Remedial Use Approval, I agree to fulfill my
responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10)
and the Approval
❑ LI For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to
provide written notification of the Approval to any new Owner, as required by
310 CMR 15.287(5)
U✓ ❑ If the design does not provide for the use of garbage grinders, the restriction is understood
and accepted
❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify
or take any other action as required by the Department or the LAA, if the Department or the
LAA determines the System to be failing to protect public health and safety and the
environment, as defined in 310 CMR 15.303
1 , st V- agree to comply with all terms and conditions above.
o ert. Owners p `�r nted name
/I( Iv 14
4
<—A*erlVwners Signature t Da e
Note: This form must be submitted alone with the septic system disposal works permit
application for all I\A systems including new construction, repairs\upgrades, with and
without aggregate (stone) and with conventional design criteria or credited design
criteria.
Q:\Septic\IA homeowner certification.doc
Town of Barnstable
°ft"E l°yti� Regulatory Services
N
Thoma's F. Geiler, Director
* sexxsrAWA
6 9 � Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Desicner Certification Form
Date:
Designer: 1 t'lAC..�.T�wvtS Installer:
Address: I y k l CsJZ Address: Z o-Y, (o G
On < < S was issued a permit to install a
(date) (installer)
qr
septic system at ye-OL based on a design drawn by
(address)Q� dated 7 (ID//y
(designer)
�I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 1011 lateral relocation of the SAS or any vertical relocation of any component
of the septic sy tem) but in accordance with State & Local Regulations. Plan revision or
certified as-bu1, by designer to follow.
SHAWN cyG�
-a
o MacINN N
CIVIL
(Installer's Sign a e) �No.413280
ISTE��c
SS��NAL.EN
(Designer's Sign' tore) (Affix Designer's.Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBBLIC 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.
i
Q:Health/Septic/Designer Certification Form
i
Town of Barnstable P tt
Department of Regulatory Services
oF ► Public Health Division Date llillzk
Street,Hyannis MA 02601 4� /
BMWSPABM Fee Pd. /10
—�
Mnss.
1639.
iOrFntura Date Scheduled , Time
4
Soil Suitability Assessment fog S ispos
Performed By: _�;44WA> 1_VK. �t ,f �� Witnessed By: /"�fl
v LOCATION & GENERAL INFORMATION
Location Address Owner's Name
972 River Road Scott Meyers&Ashley Stancil
Marstons Mills Address
972 River Road,Marstons Mills
Assessor's Map/Parcel: 045/010/001 Engineer's Name
Shawn Maclnnes,PE
NEW CONSTRUCTION REPAIR X Telenhone# 508-274-2091 Land Use wta) Slopes(%) Surface Stones P6"0,-,t
Distances from: Open Water Body 7 ft Possible Wet Area '1 /00 ft Drinking Water Well leo ft
Drainage Way ft Property Line 7 l v It Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proxim& holes)
o
q o �`•' I,.1' � ' ._ -� ,fir
t,
'W y' ^ , 5 bA U3iYA'•-`83tYA—"8.ilYA"'�3rA 1O. -
'CZn
VVtea"-�masu ,1.. t7 9i
AA
Parent material(geologic) C�LA•C1f1•(, CIv.-eaq,rl} Depth to Bedrock
L s
= Depth to Groundwater: Standing Water in Hole: p 3 Weeping from Pit Face p
7 3
Estimated Seasonal High Groundwater ! 3•�
DETERMINATION FOR SEASONAL HIGH WATER TABLE,
Method Used:
Depth Observed standing in obs.hole: 23 in. Depth to soil mottles: in.
` Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
DEEP OBSERVATION HOLE LOG , Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel)
- ZZ 3 4,S
ZZ -[20 C h, S
DEEP OBSERVATION HOLE I.OG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel)
':DEEP OBSERVATION HOLE-LOG Hole#
Depth fromSoil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency %Gravel)
DEEP OBSERVATION HOLE LOG -..Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel)
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No Yes `
+ Within 100 year flood boundary No Yes
• OMPLETE,THIS SECTION ON DELIVERY.
® Complete items 1,2,and 3.Also complete A. Sig aturP
item 4 if Restricted Delivery is desired. X ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received.. C. ate f Delivery
■ Attach this card to the back of the mailpiece, tc
or on the front if space permits.
D. Is elivery address differen v� 1? ❑Yes
1. Article Addressed.to: I ES,enteer�livery address el W �No
\-.1 61 D
Cott W.,.Myers & Ashley E. Stancil i 3: Se i Ty
072 River Road ❑c Mai presicelpt
it
0 Regis
d ❑Retu forMerchandise
Marstons Mills, MA 02648 ❑insured Mai .o.D.
4. Restricted Delivery?(Extra Fee) p Yes
I 2. Article Number'
(Transfer from service labeO M 7 012 10]; 0 0 0 0 2�8 51 3 6 41
i IDS Form 3811, February 200d Domestic.Return Receipt 1.02595-02-M-1540
I.
I
UNITED STATES POSTAL SERVICE First-Class Mail
- Postade&Fees Paid
USPS
Permit No.G-10
Sender: Please print your name, address, and ZIP+4 in this box •
I
I Town of Barnstable M
Regulatory Services Department
Public Health Division
200 Main Street
Hyannis, MA 02601
s�,l Iiiii } }}�}}Hill" 9FJIIJI!`e}tili�i
e
Town of Barnstable
Bares
Regulatory Services Department
�,� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scaii;Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL 4 7012 1010 0000 2851 3641
June 12, 2014
Scott W. Myers & Ashley E. Stancil
972 River Road
Marstons Mills, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
• The septic system located at 972 River Road, Marstons Mills,MA,was last inspected
on 5/28/2014, by Sean Jones, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system" Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Need to replace distribution-box; the box shows signs of rotting and colapse
• Need to replace leaching pit; pit is full and not leaching.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER OPER OF THE)3OARD OF HEALTH
Thomas McKean, R.S. CHO
Agent of the Board of Health
•
Q:\SEPTIC\Letters Septic Inspection Failures or Future Ev1\972 River Rd MM Jun 2014.doc
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2988
it
Logged In As: Parcel Detail Tuesday, June 10 2014
Parcel Lookup
Parcel Info
Parcel E045-010-001 W___._ __.__._._� Developer LOT 1
ID
Lot
Location;972 RIVER ROAD Frontage Fj75
Sec F_ f Sec F-"--- --�-{
Road Frontage
Village IMARSTONS MILLS ( Fire IC-O-MM �
District
Town sewer exists at this Road
------� 1373
addressNo Index
Asbuilt Septic Scan: Interactive � 2
045010001_1 Mapt
Owner Info
Co- _... _
Owner IMYERS,SCOTT W&STANCIL,ASHLEY E Owner
Streetl.972 RIVER RD Street2
City IMARSTONS MILLS 1 State[MTJ Zip 02648 Country
Land Info
.......... _ ......__.......
..".
Acres 1.28 Use[Single Fam MDL-011 Zoning[RF ^ W._..__� Nghbd j0105�___
TopographyiLevel Road Paved
Utilities�Septic,Well,Gas _ Location Rear Location
Construction Info
Building 1 of 1
Year Roof Ext,.__. �� "'
Built 11979 Struct[Gable/Hip Wall Clapboard
Living 11188J� �� Roof[A ps h F GIs/Cmp ACINone���
Area Cover' Type'
Int� Bed
Style Cape Cod ��� Wall[Drywall Rooms
'3 Bedrooms
Model lResidential Int Pine/Soft Wood Bath 12 Full 51 AS
Floor Rooms
Heat f.�otA� Total
Grade irAe '
, 5 Rooms
Type Rooms'
Heat; Found-
stories 11 1/2 Stories Fuel, ation ETyp[cal
Gross
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2988 6/10/2014
1
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3 Commonwealth of Massachusetts
Title 5 Official Inspection Form
_,.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ti
ate. 972 River Rd -
..._.... ..............:..-._.._-__-.._
Property Address
Ashley Myers
Owner ---
information is
Marstons Mills Ma 02648 5/28/2014 .required for every . __. Mills _..____ _._.._
page. Cityrrown --- —
State. Zip Code. Date of,Inspection
Inspection results test be submitted on this focus. Inspection forms may not be altered.in any
way. Please see:completeness checklist at the end of the form.
_.._._. ......-........
__
Important:When filling out forms A. General Information
on the ly the er, I
use'onlythe tab
1. lnspector:
key;to move.your
cursor-do not Sean M. JoneS
use the return
. . .__ _ ..._
_. ...
key. Name olnspector
Cpewide Enterprises
.. ...... ..._..
r� Company Name
153 Commercial St.
e Mash ee Ma 02649
p- _ ._...-" ..... ......... - _. _.._
Citylr"own State Zip Code
508-477-8877 S1 4522
----- — __. ........ __........
Telephone Number License Number
_...........
B. Certification
I certify that I have personally inspected the sewage disposal system at this"address and that ttie
information reported"below is true, accurate and complete as of t' e time of the inspection. The inspection
was performed based on my training and .experience in the.proper,fu nctioni and maintenance bUon site
sewage.disposal systems. I am a DEF approved system inspector pursuant'to Section 15.340 of
Title 5'(310 GMR 15.O04 The system:
❑ Passes
❑ Conditionally Passes .. ® Fails
Zz
❑ Needs Further.Evaluation by the
the Local Approving Authority
5
_. .....:......................... __ __..._......:._. /28/2014
............ - .... ....... a.. .
Inspector's Signature `'" Date t
The system inspector shall submit a copy of this inspection report to the Approvirig.Authority(Bard
of Health or DEP) within 30 days of completing this inspection. If the system is a sharedrystem>or
has a design flow:of 1.0.,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER. 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 nest address how;the system Will perform in theJi ture under`.
the same or different conditions of Use.
I
t5ins•3/13: Title 5 bf dal Inspec' Fri:Subsut`ace Sevrage Disposal,Systen•Page i..of,7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•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
,M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. CitylTown 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 (cost.):
❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
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/z day flow
L,,5,ns /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
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:
❑ Z 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
;M5 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? Include laundry system inspection P 9 Y ( Y Y P
information in this report.) El Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2013--47,000G &2012 —49,000G
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant
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:
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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):
Ll&n. /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 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system installed 1979, leach pit added 10/19/1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
101,
Depth below grade: 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.):
Joint were ok, no leaks, vented through the roof
Septic Tank (locate on site plan):
Depth below grade: '5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gallons
Sludge depth:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 972 River Rd
Property Address
Ashley Myers
ers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
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
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Water level was at outlet invert. Tank was decaying, the exposed concrete above the water line was
brittle and rotted. tank needs to be replaced.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information Is required for every Marstons Mills Ma 02648 5/28/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
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
Oil
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.):
Distribution box was rotted and the sides were caving in. Box has 2 outlets with speed levelers. The
water flow inside the d-box was diverted to the newer pit that was installed in 1995.
- 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.):
/
r
* 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:
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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.):
leach pit#3 on asbuilt is original from 1979. This pit was found to be dry at the time of inspection due
to the flow being diverted towards the new leach pit in the d-box with speed levelers. There is an
ynspection report dated 9/6/95 indicating that this pit has been hydraulically overloaded.
The observed water level in the new leach pit installed 10/19/95 (leach pit#4 on asbuilt)was 1"
below the inlet pipe with stain lines higher into the riser.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
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
�z J a
Subsurface Sewage Disposal System For -Notfor Voluntary Assessments
r 972 River Rd
g
Property Address
Ashley Myers w
Owner __..,...... _
Owner's Name
information is Marstons Mills Ma 02648 5/2812014
required for every _ .. ........................ .._....... _ _, ...... ........ .._:._.
page. Clty(Town State Zip Code Dafe'of Inspection
D. System Information (coat.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate.all wells within 10.0 feet. Locate
where public water supply enters the building. Check one of the boxes below:
Z hand-sketch in the area.below
❑ drawing attached separately,
A- 2 2i
_ ?. '
t5ins-8m Title S Official Inspection Form)Subsurface Sewage Disposal:System.--Page 15 of'17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
page. CitylTown 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: 124
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 972 River Rd
Property Address
Ashley Myers
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/28/2014
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
BORTOLOTTI CONSTRUCTION, INC.
* SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop ._ _ _ j
Date of Inspec} Map arcel Owner i
q -�S OlO.00 1y�
PART A — CHECKLIST '
CHECK IF THE FOLLOWING HAVE BEEN DONE:
PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH.
1/NONE OFTHE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A.
HE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK--:UP.
THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS-INSPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,
DEPTH OF SCUM.
HE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED,BY NON—INTRUSIVE METHODS.
THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL
No of Bedrooms S3No of Current Residents Garbage Grinder
Xas _Laundry Connected to System Seasonal Use
NON RESIDENTIAL:
Calculated flow
WATER.METER READINGS,IF AVAILABLE:
GALLONS
P ing Records.and.Source of Information:
r�. o -off ,�e 06--wev
bOKO
SYSTEM PUMPED AS PART OF INSPECTION? 6 IF YES,VOLUME PUMPED= GALS
Reason for Pumping:
TYPE OF SY TEM
Sep 'tank
tic, box/soil absorption system
Single,Cesspool Overflow Cesspool Privy
Shared system (rf yes, attach previous inspection records, if any)
Ot4,9jr(explain);
Approximate age of aU components. Date installed,if known. Source of information.
Y29 i 7�
SEWAGE ODORS DETECTED WHEN ARRIVING ATTHE SITE? /�d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SEPTIC ANK:
Depth below grade: / ,, Dimensions: Q ,
Material of construction: oncrete Metal FRP Other}
Sludge Depth Distance from top of slydge to bottom of outlet tee or baffle
6 11
Scum.Thickness „ Distance from Top of Scuff to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle6 j
'Comments•
9
O'� 7�j r✓ l �L
DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
C r- 1 U Q'>z
S
PUMP CHAMBER: Pumps in working order?
Comments:
SOIL ABSORPTION SYSTEM (SAS):
IF NOT PRESENT,EXPLAIN:
Comments: _
�s
CESSIROOLS:;A05 Number and configuration
Depth-.top�of:liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indication;oUgroundwater:inflow(cesspool must be pumped)
Comments:
PRIVY:..
Matsrials,of,construction
Dimensions' Depth of solids
Comments:.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C — FAILURE CRITERIA
Qp.dlcaIe,•Y-yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.)
Backup,of;$ewage into Facility?
Al- / Discharge or ponding of effluent to the surface of the ground or surface waters?
/V Static liquid level in the districution box above outlet invert?
Liquid:depth.in as 6"below invert or available volume, 1/2 day flow? `
Required pumping 4 times or more in the last year? Number of times pumped
/V Septia`:.tank,is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration?
aankfailure imminent?
/,t/ Is any::portion of the SAS,cesspool or privy, below the high groundwater elevation?
Within50,feet of a surface water?
Vithin:100:feet of a surface water supply or tributary to a surface water supply?
Within a'Zone I of a public well?
-Within.50 feet of a private water supply well?
Within..50feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
:1ess1han1001eet but greater than 50 feet from a private water supply well with no acceptable water
quallty;analysis? If the well has been analyzed to be acceptable, attach copy of well wateranalysis for
conform bacteria.volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
INSPECTOR ' .ROBERT J:;�BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS '
COMPANY. BORTOLOTTI;CONSTRUCTION INC. MA 02648 (508)771-9399
w.:Zi.
CERTI FICATION TSTATEM ENT
I'CERT1FYTkJATW�H&
WePERSONALLKINSPECTED THE SEWAGE DISPOSAL SYSTEM.AT THIS ADDRESS AND THAT THE EINFORMATION:
REPORTED�i,SHRUE ACCURATE'AND,COMPLETE.AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
4 :RECOMMENDATIQN1REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND IXPERIENCE
IN THEPROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS.
`' CHECK ONE
LL'
I.HAVE NOT FOUND ANYIINFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT.PUBLIC
SALT -0. THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED AREAS
T TED,,iINM "FAILURE CRITERIA°:SECTION OFTHIS FORM, -
hNAVE.DEiERM)NED THATTHE`SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
:310 CMR 15 303 THE.BASIS.'FOR THI8 DETERMINATION IS PROVIDED IN THE"FAILURE:CRITERIA':SECTION-OF THIS'
....FORM •,. ,.. ..
INSPECTORS:SIGNATURE
DATE;
ORIGINAL.TO S)gWAipNNE COPIES BUYER(if,applicabie),APPROVING AUTHORITY
Y
1 -- ;SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART B — SYSTEM INFORMATION (Continued) •
SKETCH,O.F- SEWAGE1DISPOSAL SYSTEM:
INCLUDE TIE8:'CO:ArLEASTTWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL`W....ELL3WITHIN 100'
� b
�o A
Jr'
0
DEPTH TG OUNQyVATE�t; DEPTH TO GROUNDWATER
METHOD
5 �� I '�JpNORAPPROXIMATION:
BORTOLOTTI CONSTRUCTION, INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop
r
Date of Inspec} .�s Ma Owner ,p arcel 1
/ N
PART A — CHECKLIST N.
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 AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
AS=BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A.
HE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
i---THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,
DEPTH OF SCUM.
HE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED BY NON-INTRUSIVE METHODS.
THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL '
No of Bedrooms No of Current Residents Garbage Grinder
Laundry Connected to System /V( Seasonal Use
NON RESIDENTIAL:
Calculated flow
WATER.METER READINGS,IF AVAILABLE:
i
P ing Records and Source of Information:
GALLONS
b o
SYSTEM PUMPED AS,PART OF INSPECTION? O 1F YES,VOLUME PUMPED= GALS
Reason for Pumping::
TYPE OF SY TEM
`Septicnk/distribution box/soil absorption system
Single, ,esspool Overflow Cesspool Privy
w Sha(.ed',system'(if yes, attach previous inspection records, if any)
s a OtferX(ex
plain),
Approximate aee o!4 1 components. Date installed,if known. Source of information.
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? /Y d
r,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
PTI ANK
Depth below.,grade:"/ Dimensions:
Material of construction: oncrete Metal FRP Other}
Sludge Depth /� Distance from top of slydge to bottom of outlet tee or baffle
6
Scum Thickness Distance from Top of Scuff to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffleb
Com ants
2 � C ls. �;c� ;► i �v�e�s q�j
M IV
� e iG `dam
DISTRIBUTI ON,BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
p
Comments:
� N"4'/;
s
PUMP CHAMBER: A10 Pumps in working order?
Comments:
SOIL ABS RPTI .N SYSTEM SAS
IF NOT PRESENT,EXPLAIN:
Comments-
CESSPOOLS" 6. Number and configuration
Depth-top of-liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
indication of groundwater inflow(cesspool must be pumped)
Comments:
PRIVY:
Materials.of Co n
Dlmenskxt Depth of solids
Comments:.
r - I _ -
a '
{ ' _';S,U8SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
"q ,w
2 >` PART B - SYSTEM INFORMATION (Continued
k ki q _
SKETCH.*OFVSEWAGE,DISPOSAL SYSTEM:
INCLUDE?IEs TO AT-`.LEA$TTWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL'WEL,WITHIN 100'
�1 1
a'
(o
3�
o'
`; DEPTW T GOY D
DEPTH TO GROUNDWATER
APPROAMATION:
Veg OF 7 Tjer t/0),
dt
t
s7�' Ear .mot.
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C — FAILURE CRITERIA
(indlcafe,Y-yes N=no ND—not determined.Describe basis of determination.If"not determined",explain why not.)
Backupof Sewage into Facility?
Al Discharge or ponding of effluent to the surface of the ground or surface waters?
/V Static liquid!.level in the districution box above outlet invert?
Liquid depth in ees lop n 6"below invert or available volume, 1/2 day flow?
Required pumping 4 times or more in the last year? Number of times pumped.
4t'
Septle-tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration?
;tank,failure imminent?
Is any�p:ortion.of the SAS,cesspool or privy, below the high groundwater elevation?
Within%Jeet of a surface water?
='Within 100*feet of a surface water supply or tributary to a surface water supply?
Within,atZone I of a public well?
-With in,50 feet of a private water supply well?
Within b0 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
:Less thand00 feet but greater than 50 feet from a private water supply well with no acceptable water
hquall#y=analysis?' If the well has been analyzed to be acceptable, attach copy of well water analysis for
colrform'bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D CERTIFICATION » •b
INSPECTOR ''—ROBERTJ BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS
' C0.1011 ,f ,>BORTOLO.,TTI;CONSTRUCTION INC. MA 02648 (508) 771-9399
CERTIFICATION STATBAENT
I CERIIFYTIFIT I,HAVE PERSONALLY:INSPECTED,THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION'
REPORTED„J,O RUE;ACCURATE AND-COMPLETE AS OF THE TIME OF INSPECTION, THE.INSPECTION WAS PERFORMED'AND'ANY
PECOMMENDATION=REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SrrE SEWAGE DISPOSAL SYSTEMS.
y .i 4
CHECK ONE::
LHAVE NOT FOUND ANY.,INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
EALTH4ORTHE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED AREAS
STAxTEDJN. g FAILURE CRITERIA"•SECTION OF THIS FORM.
'. "I HAVE=DETERMINED THOTHE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
--,310 CMR�15 303 THE BASIS.FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE:CRITERIA",SECTION.OF THIS;,
FORM
INSPECTOR'S SIGNATURE
7 - .p _ -
DAM
ORIGINAL,PfO 8YSTEMOaIV ElR,COPIES BUYER(ff:applicable),RPPROVING AUTHORITY
f J ;
i y Ya13 fi. '7
D
DATE 10/20/05
PROPERTY ADDRESS 972 River Rd
Marstons Mills
MA 02648
On the above date, the septic system at the address above was
Inspected.
This system consists of the following: "AUNY&,-tr5---
1. 1- 1000 ga. Po.n 3epi-is .tank,,
2.- 1-Diz.ta.igut.ion gox.,
3., 1-1000 gaiioa ieach.ing fit,
4.1 1-600 gaiion ieach.ing �2it .new .in 1995
Based on inspection, I certify the following conditions:
5., 7h.iz .ins a 7.it.ee T ive hep.t.ic zyz.tem (78Code)
6., The ZeR.t.ic *,61 em .ins .in /2a0/2ea woak.ing oadea a.t .the
12aezerz.t .time.- Odd 12.i.t ha,3 V o� wa.tea .in .it.� New 600 gaeeon
ieach.ing p.it .iz 8" ;eaom /2.il2e..
SIGNATUR i N`
a t:
Name: Robert A. Paolini
�y
Company: Joseph P. Macomber & Son Inc
Address: P. O. Box 66
Q
Centerville, Mass 02632 '
Phone: 508-775.3338 or 508-775-6412
ry �,
JOSEPH P. MACOMBER & SON,: INC.
Tan ks-Cesspools-Leachfields
Pumped.& Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 026.32-0066
775.3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE`OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
0r. i
TITLE 5
OFFICIAL INSPECTION FORM—.NOT.,FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PARTA
CERTIFICATION
Property Address: .. 972 River Rd
Mars tons Mi11c MA 0264.8
Owner's Name: John ohmann
Owner's Address: . :SamP
Date of Inspection: 164 o n) /n�4F4 _
Name of Inspector: (please print) Ro-b.,grt A_ P o.lini
Company Name: _2. P,Aacomle)t S:o.n Inc.
Mailing Address:
en ez77 e, 8476.-02632
Telephone Number: 5 0 8-7 7 5=3 3 3 8
CERTIFICATION STATEMENT
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
approve
d s stem inspector pursuant to=.Section.15:340 of-Title 5(310 CMR M000). The system:
.y p
XXX Passes
-Conditionally Passes
Deeds Further Evaluation by the Local Approving.Authority
F '
Inspector's Signature: Date: /�ZO.� .
ort to the A rovin Authority(B
oard of Health or
The system inspector shall submit a copy of this inspection rep .,pp g h+(B
Y
within 30 da s of com letin this inspection.If the system is a shared system or has a design flow of 10,000
DEP) Y P. g
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.
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.
Title 5 Insnection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION:.FORM-NOT FOR VOLUNTARY ASSESSM-9NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION(continued)
Property Address: 972 River Rd
MarStCLS Mi_1 1 c MA 0264f;
Owner: Tnhn Ohmal3n
Date of Inspection: 1 0/2 0/0 5
Inspection Summary: Check A;B,C,D or E/ALWAYS-complete,all of Section.D
A. System Passes: I/cS
NO I have not found any information which indicates that any of the failure criteria described jin 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
Se.pt.ie Zy.51-em .is in R2o/2e2 wmk.inq o zdea n.t .the /22ebent
B. System Conditionally Passes:
NO 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.
NO 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:
NO. 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:
NO The system requited 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:
2
Page_3 of 11
OFFICI
AL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTI.FICATION(continued)
Property Address: 972 River Rd
Ma 48
Owner:. John Ohmann
Date of Inspection: 10 1 '^10
C. Further Evaluation is Required by the Board of Health:
N Conditions.exist whichrequire further evaluation by the Board-of Health in.order to determine if the system
Ts failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines
protect accordance public health,safety and the environment:the
system is not functioning in.a manner which ! !
no Cesspool or privy is within 50 feet of a surface water
n oo 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:
no The system has aseptic 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.
no The system has a septic tank and SAS and the:SAS is within a Zone 1 of a public water-supply.
. no The system has a septictank and.SA&and the SAS is within 50 feet of a private water supply well.
no The system has aseptic tank.and SAS and the SAS is less than10 ufneet 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
facility nd
bacteria and volatile organic compounds indicates that the well is free from pollution fromthat provided that no other
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSA)G SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 972 River Rcl
Mg Gt-c)nG Mil 1 -- ' MA 02648
Owner: jnhn nhmnnn
Date of Inspection:l0120 10 c;
! D. System Failure Criteria applicable to all systems:.
You must indicate"yes":or"no"to each of the.following:for all inspections:
3 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 avail ablevolume is less than'h day flow
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.
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.i.of a.public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well. i.
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 fora.]
NO (Yes/No)The system fails.I have-determined that.one or.morOpf the above.failurc,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 1.0,00.0 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
X the-system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(1Tnterim 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
15.104.The system owner should contact the appropriate regional.office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL;SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 972 u j vor RC
mar,.tonc NJ I fir, . 02648
Owner: Tnhn Ohmann
i Date of Inspection: 1 0/2 0/0 S
Che
ck if the following have been done.You must indicate` for"no"as to each.of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows hi the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?Of they were not available note as N/A}
X Vas 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 condition
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
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes
Existing information.For example,a plan at>he Board of.Healtlt.
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)]
s
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE 1DISAOSAL:SY'STEM.,INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 972 River Rd
Mars tons Mi11c MA 02645
Owner: John Ohmann
Date of Inspection: 1 0/2 0/0 5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. :.3 Number of bedrooms(actual): 3
DESIGN flow based on 310 0I 1k 15.203(for example: 10 gpd x#of bedrooms):3 3 0.
Number of current residents: 2
Does residence have a garbage grinder(yes or no):a o
Is laundry on a separate sewage system(yes or no)+z X. [if yes separate inspection required]
Laundry system inspected(yes or no):n o
Seasonal use! (yes or no):a o 2004=8, 000.gaeeoa.6 91 c7_21., 91 new watez
Water meter readings,if available(last 2 years usage(gpd))Z 0 0 5=3 2, 0 0 D ga o n s g [7=8 7. 67
Sump pump(yes or no): n o
Last date of occupancy: /2n e z e n t
COMMERCIAL*USTRIAL
Typeh of estalz `.lint: N/4
Design flow(l:as d on 310 CMR 15.203): gpd
Basis of dosi�n`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: 9114105 12um/2 7ank P., (Iacomge2
Was-system pumped as part of the inspection(yes or no):
If yes,volume pumped:__gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM.
X 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):
Apppi ytte age ofall components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): rz o
f
Page 7 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address: 972 River. Rd
Ma:rstojis Mills MA 02648
Owner: John Qhmann
Date of Inspection: 1 0/2 0/0 5
BUILDING SEWER(locate on site plan)
Depth below grade: 3 0"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line: 10
Comments(on condition of joints,venting,evidence of leakage,etc.):
aO-.nits appeal i-1 ht V aLLJ 1hnmigh hni/ 6o >>nnf
SEPTIC TANKV e 6(locate on site plan) 1000 ga.P i o n
Depth below grade: 2 4"
Material of construction.7concrete 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: 8' V X5 ' 8"X4 10"
Sludge depth: taace
Distance from top of sludge to bottom of outlet tee or baffle: taa ce
Scum thickness: t z a c e
Distance from top of scum to top of outlet tee or baffle: t 2 a c e
Distance from bottom of scum to bottom of outlet tee or baffle: t yz a c e
How were dimensions determined: m e a z u 2 e d
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
PtLml2 tank .
lank 1z ztzuctun
n
GREASE TRAP.. o_(locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
G2eaze tad/2 i,3 not 2e,6ent.-
I
Page 8 of 11
OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM �
PART C
SYSTEM.INFORMATION(continued)
Property Address: 972 River Rd
Marstons Mills MA 02648
Owner:
Date of Inspection: 10 2 0 0 5
TIGHT or HOLDING TANK!V0 (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.):
7.igh.t o2 hoid.ing . .tankh ate not /22.e.3en.t!
DISTRIBUTION BOX:J?-3 (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.):
/30x .i.s eevee Ka-3 31a.teaa.P.6 , No :sotid ca22u ove2. No eeakage
.in 02 outo7p- e'ox
PUMP CHAMBER: n o (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.):
pump chamgea .iz ' not 122e.6ent
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: 972 River Rd
Marston s Mills MA 02648,
Owner:. John Ohmartn
Date of Inspection: 1 R/2(1/Oa
SOIL ABSORPTION SYSTEM(SAS): {locate on site plan,excavation not required)
If SAS not located explain why-..
Located .see ea e 10.1
Type
XX leaching pits,number:2
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic.failure,level of ponding,damp soil,condition of vegetation,
etc.):
•� Loamy to med-ium, �.ine e¢nd.� No �.iny,3 o ond.in on ¢.i.�uze. So.i.ez
¢2e 2y. vege a ion 7z noa�nae.,
CESSPOOLS:n o (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: esr no):
Indication of groundwater inflow(y
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.
ce.6.s/2oo1.6 a,%e not /r?esea
PRIVY: nO (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
of soil,signs of hydraulic failure,level of ponding,
Comments(note condition condition of vegetation,etc.
la.ivy 46 not 122ehernt
ram..
9 _
Page 10 of 11
OFFICIAL INSPECTION FORM:—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSUR A:CE SEWAGE.DISP.OSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATI.ON(continued)`
Property Address: 972 River- Rd
Marstons Mills MA 02648
Owner: John ohmann
Date of Inspection: 10 2 0/0
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.
I
i
� - 1n
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY C ION FORM ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE
PART.0
SYSTEM INFORMATION(continued)
Property Address: 972 River Rd
Marstons Mills MA 02648
Owner: John Ohmann
Date of Inspection: 1 0/2 0/0 5
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water K• feet
Please indicate(check)ail methods used to determine the high ground water elevation:
,NO Obtained from system design plans on record-If checked,date of design plan reviewed:
cle.6 Observed site(abutting-property/observation hole within 150•feet of SAS)
Checked with local-Board of Health-explain: ? ° r /z r]
n o Checked:with local excavators,installers-(attach documentation)
Accessed USGS database=explainAt;612 Wn.'gaanh.ta, �e'�ma.,u•s
�—. You must describe how you established the high ground water elevation:
1l�sed. : Ca e Cod COmm.i<S.ion 1datea 7a�,ie Coritou?,s ,end P u&. .ie lVate2
iVeii head aotection aaeas ma Se t 9995
/Jatea 2e�ouace� o ice ca e cod comm.ihion.�
Leaching
Pit : ,eet
roundwate Feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
G � B .}
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is/_
feet.
� 11
:01 IN C Clio
:r•nrnr+re—tsirsr--rrarnrmrrrre+re•nrrati+parare:•r.Te�mraenrrsrm+ +ss•+•nures-rr.amnsn . . nrnrir-.�rrsr.- c;-.r••F
TOWN OF BARNSTABLE BOARD OF HEALTH
SUDSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART' D •- CERTIFICATION
p•{Tr{T—•:'i T•tllR7'JST1Cr'P�i7'�R •lT� ifRl :TI`TT'-'T!•1!•�••�
.•••L:•i-T•:•::i�T.SI"'•�TTTTI•ITtT.t•IT7i'.1RiR -
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
972 /2.ive2 Road
STREET ADDRESS
ASSESSORS MAP, BLOCK AND PARCEL # 045-010-00.1
OW.NER' s NAME aohn Ohmann
flTRA91'1�'�TTTII
PART U - CERTIFICATION
NAME OF INSPECTOR RogeAt paoiin4'
COMPANY NAME aozeph P flaeom&e_''''&` Son Inc
COMPANY ADDRESS Box 66 Centeavd-' e 0a6'.s 02632
Street Town or City state LIP
COMPANY TELEPHONE ( 508 ). 7:75 " 3338 FAX ( 508 .)790 - 1578
R
CERTIFICATION STATEMENT
I certify that I have personally. .inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
omplete as of the time of.,inspection . The inspection was performed and any
recommendations regarding upgrade , . maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems -
_
Check one:
i
XXX System PASSED i
The inspection iahich I have conducted has not found any information
which indicates that. the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this. form.
System FAILED*
The inspection which I have con cted. has found that the system fails to
protect the ilublic health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as .specifically noted on PART C FAILURE
CRITERIA of this jinspec i
Inspector Signature Date
ne copy of this certification must be provided to the OWNER, the. BUYER
where applicable ) and the BOARD OP' HEALTH. ,
* � r .
If the inspection FAILED., the owner or operator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.;10. CM.R 15 . 305 .
TOWN OF ARNSTABLE -
LrAT10rz Xl ile I SEWAGE # 1 5=I72V
VILLAGE /Y/�✓�f0 �/�/��S ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. /VOd/O( d7/'C��?vr 771`--�;3&
SEPTIC TANK CAPACITY 0AA 6-X 14"4 C
LEACHING FACILrrY: (type) 4AX (size)
NO.OF BEDROOMS
MOWER OR OWNER ��G; �il
PERMUDATE: 2///�qS 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
°'� Y, "
31`4
tow iokt
a �
Fee
THE COMMONWEALTH OF MASSACHUSETTS --��
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Mie;po$dr *p5tem CCon5truction Permit
Application is hereby made for a Permit to Construct( )or Repair(KK an On-site Sewage Disposal System at:
Loca[en Address oSLot No J � Owner's Name,JAd7d�ress�and Tel.No.
p/ Qs��t5Q�►.S<1.L vu/ uS , �N Q�'-LT �i�L ! aa&el
Instal Name,Address,and Tel.No. Designer' Name,Address and Tel.No.
L,f' —jjut� GfJ�JS.
Zb Type of Building:
Dwelling No.of Bedrooms ..3 Garbage Grinder( )
Other Type of Building /1.jFXr0 No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow hw7-70 gallons.
Plan Date U / r-77 Number of sheets Revision Date
Title
Description of Soil
Naturg off Repairs or�Alte ations(A r when applicably /�,0 0 /L g,�s&t Jf_ P C7 Pb2.
'j�// Ai . ,,�—fi x r�r I
Date last inspected:
Agreement:
The undersigned agrees to ensure the constructionPlaiwe-of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this oard of Heal
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued
3• - op., U . _ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS C' C
01pplication for Migool *p5tem Congtruction Permit
S
Application is hereby made for a Permit to Construct( )or Repair(ems)an On-site Sewage Disposal System at: <.
Lo Address of Lot No. Owner's Name,Address and Tel.No.
COcO 7�- /Ld Jf/l;. /&14Z PO G(Z-E,&.1 ZI E
/1't
,44CS_rbI JS Iv/ t-LS / VV14 q'6 97..1- (KJI i f./L.
`lit�L/L�'�S r✓t�ttJ �/V1�• G�Cr 4/�'
a
Insta Name,Address,and Tel.No. Designer' Name,Address and Tel.
i,,6rzxt;�T—o
. J ! t.
Type of Building:
Dwelling No.of Bedrooms —3 Garbage Grinder( )
Other Type of Building /L,5x No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date 71 r 1-7-7 Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alte ations(A r when applicably /�0 r�f"f_
��eJ IV p� �� e ?,c�
u
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction aid- Ee-of the afore described on-site sewage disposal system
k ..
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this oard of Healt
Signed------- / ' Date
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS d y�_Q/�
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(°-/}on
by ;&0/-7"6ur 1-7 COQ�if jCTTa1 for -7UD0 ✓✓1 c14f—," cE
as v f/L.. !LoAb , ,7, 1-1 t v,-s has been constructed t* a cc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No.1r--" 123 dated j 9
Use of this system is conditioned on compliance with the provisions set forth below:
l
Fee ✓ 4
i
THE COMMONWEALTH OF MASSACHUSETTS `
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
Mi5pool *pgtem Construction Permit
Permission is hereby granted to U�/ CbYJ (�TT C,03
to construct( )repair(b4.an On-site Sewage System located at
6 rw ✓y) t Lt-S
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must a completed within two years of the date below.
Date: A Approved by
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CERQT(hF(�ICATION OF SKETCH ANDAPPLICATION FOR A DID
;3A at.,3 rz' r. LwOi�l\�7
SPOSAL t F
r CONSTRUCTION PERl1IT(WITHOUT DESIGNED PIANS). y
a y w'i.•.
4
r s.
r-�'s r F 4 -s Y �" F •� � r' a� �� w -� t 3; � �^ b_
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r & `
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A�'a`.e°act '�'i .t, „a vE tcra•*s'; `,3" 'i ' ,r*y' ,� a` ['-: a I' Y a,a'a„�n: t'`t r �'� F
l-� ,
Y v 7"� v. r�� 6 x�`�a�+�.���Y�� r•;"•Y- � e,r p ` >� �x�a�-9.}ti. �,� .� s,.„ spbA'S..- S� £:kn 14 !.,s'� .� R ,,r: ` ,rt�r,.
a '�S:n:„ L` rr f` >x�z " .. X: 1. :,�:✓'fc f C;'a^r y i' S ...
, , ,�'fl�f? FS
'7'f,�fAK ,i� _-a R..r,.st"^,,w,n .<..8,. ?,5^ ,x, ,4
Irimmg
5 hereby certify that the applicatton for dis osal works 4 _ } p
,. +-. S ,
�� °constNctlon etmtt st ed b me dated "
> ,r , p:x, �� , Y -concermng the
R }
�.'
}Sl
popes ty located at y'7� !RZ ,c. y, ,t`.c,S `
; r meetsall of the
followiri cntena
uA
• ere are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
fThe observed groundwater table is 14 feet or greater below the bottom of the leachingfacility
ty
There is no increase in flow and/or change in use proposed
There.are no variances requested or needed.
SIGNED : _-DATE:
LICENSED SEPTIC:SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach'i sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan sh beould subrruttedl. '
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-L,O C A T�ION SEWAGE PERMIT NO•
VILLAGE
A//,
INSTA LLER'S NAME i ADDRESS
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8 U I L 0 E R OR OWNER
A. S�
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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No..........:�1Z...... Fs$............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF.......�� .L�/1�.�i..!_.��.� .............................
App iratiou for Bi-gVvii al lurks Tomitrurtintt Prrutit
Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal
System at:
tILN., .. �........ _.. �,l�...... 1.��..5... >. ........._' --------•-----------------•---•-•----_...._..--•--•----•
Lo ti n- ess or Lot No.
.... `/ ........... ---•-••....................••••----..........-•----•-............._--......._...................._
` --•-•O---- -----------•....................Address
Ins a ler Address
QType of Building Size Lot__ .&a_____-___-S*rfeet
Dwelling—No. of Bedrooms............................................Expansion Attic (rvo) Garbage Grinder (:r o)
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Otherfixtures ---------------------------------- .....................................................
W Design Flow.___.____.1!P-----------------------gallons Pep epsen per day. Total daily flow________ ...................gallons.
el
WSeptic Tank—Liquid capacity,/A!Zc2..gallons Length_46.�6 4__ Width.Y 4 ss_ Diameter________________ Depth_.:5.. _'__.
x Disposal Trench—No_____________________ Width____.................... Total Length.........._......... Total leaching area...................sq. ft.
Seepage Pit No....... ---------- Diameter...l0._.___.___ Depth below i et__ .._...�... Total leaching area....�F.0...sq. ft.
Z Other Distribution box Dosing tank
'-' Percolation Test Results Performed by.....�p.N^r.D.___.____Ar_ ....61KOAl7.0_kC.Date...Xr4�16-.....8;"_/
,aa Test Pit No. 1_ _?. .__._minutes per inch Depth of Test Pit...f A'.__.___ Depth to ground water----- 3.-!____.___...
Test Pit No. 2..�:_:?;m_.minutesper inch Depth of Test Pit__-'I-:'_._______ Depth to ground water....e t __.__.._...
P4 ------------------------------------•---•-..----•--_-- - ------ ••----------._...---•---•----_-•.........................................................
0 Description of Soil------------ Q . 1-._./ . `.-..?sa__.1._...
..P---- .. ....... f.--- ---•--
W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------..__...__
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--........_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L ITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' sued b - rthe boa f th. 1
Sigiaed - -""'----------------- `---------_--_ ------------ ------------------
` Date
Application Approved By----- >�� �-�/-•-- /�--................ -&`2=I-"- ;7..: --------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•-.._
---------------------------------------------------------------------------------•-._............_..-------------._.._..._..--------------------...-------------------------------------------_._......_
y 7 o Date
Permit No......................................................... Issued_---�•_".l�-�-. /_.1..
- -•....................
Date
140................-.....-- FEs...a:.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T.OjCC.. A)..............OF......-V. . W.5.7... - ............................ �.
.Appliratiuu fur Uiupuual Works Toustrur#iun rrmit ,
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: .
z. .. .......... . :[�;. J4d:c.[.`:.f ... ter " ........._.....--
"" L A d e s ,, ,pr Lot No.
Address
W -----J 14 ......... ......*----•.... . `. . • ................•..... .........•.....................---............•.
r . Installer Address .
c}
Type of Building Size Lot__AA-6------..:
g ...._Expansion Attic (A,*) Garbage Grinder (op)
U Dwellin —No. of Bedrooms..:. :..::..............
Other—Type T e of.Building ..............,No. of ersons_........................... Showers —
P.i YP g..............................
p ( ) Cafeteria ( )
dOther fixtures,,,-,. -----------• ---•--.
W Design Flow_____ .t�/P.. ....:.. gallons per r-sofr per day. Total daily flow......_. ...........gallons.
9 Septic Tank—Liquid capacity/,PNO..gallons Length.a..�d.-`',.1 Width '��+�''. Dia�r te��jj.�y. .-.__- Depth-. W...:*"'
Disposal Trench No .............. Width.................... F Total I�fgth *7 d*Afa1 ea fig area.... ....sq. ft.
Seepage Pit No......f; Diameter---142........_'. Depth below inlet... '-+ ...._. Total leaching area.. _GP...sq. ft.
z Other Distribution box ( Dosing tank ( )
'-' Percolation Test.Results Performed by.... ',, .l+►t .........Ae....5!156??Z?A_l�VDate_..�V ._75?. . ;"..... +
,`ja Test Pit No. 1:4-2 ._n._minutes per inch Depth of Test Pit.../;_°....... Depth to ground water.._!_k..
r=. Test Pit No. 2__.4, -...minutes per inch Depth of Test Pit.. ..........Depth to ground water........................
a • ----•--•••••---- ----- ----- .... .•-•-- •• .........................................................
0
Description of Soil............
0 �!1t.Z�1 e A1:er-/-E:ts!!"1." ���9i�..�.�....... u��els,�►
W .................................-------------- --•--------•------••----•----------............•. ••............._.._........__ :.,
U Nature of Repairs or Alterations—Answer when applicable
............................................-.....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned fu!�Ojer agrees not to place the systemin.-
operation until a Certificate of Compliance has been • sued�t bo� lth.
7 -
Si 'ed _
- --._
--------
�
Application Approved By............. --- e ••..... - .... � Y
} Date
Application Disapproved for the following reasons:....................................................................
,''
` Date
Permit No.... - ---•---•----•-------------- Issued.--•7; ---------- ......... .............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r.
:.........................................OF...........:...................................... "
Tatifiratr of Tumpliaurr
THIS IS TO CERTIFY, That.the,I,ndividual Sewage Disposal System constructed ( ) or Repaired ( )
b
Y ..............•------•-- ----
.. -•-------•------••---.._.._..
, I
fat .. f
~ ...._..
has been installed
in accordance with the provisions of TITLE 5 of The State Sanitary Code as desc4ed in the
application for Disposal Works Construction Permit No.......................................... dated----------......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® S A.kG# RANTEE THAT THE
SYSTEM WILL'FUNCTION.'SATISFACTORY. y. T
DATE.......�-1e` �............................................ Inspector---- �V.. - . .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i 67p; I -Add r"
iNo..............�..----• FEE........................
Disposal Varks Touu#.rudiuu ramit
Permission eby granted...... ......................
to Constivu� ) o a air ( n Iric�+lidu e r a Disposal System i
at No
. . K
Street a _7e
as shown on the application for Disposal Works Construction Per o._.._,___�.._ ted.>_...._�. .---------------------
DATE .
s ..........................
`�y:.� M � Board of Health �;
x
.....'•--°�-----••-•-- ----------------••-----------------------------....... .
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
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- /g . LOAM AND
CAIAVIeL
ELtV, f3t37IOM A•'llD _r i"hib. 1<landfc 'PTIC
Locu
g7" HOLES x
LOT l i
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�0.� •" - T___...- ___._.,.__:.__... ..•.,: -_.__ ...._r jNI:�L-,t2V/QC15' CO.VE�'
-� MANHOLE Ca✓ETz TO �xTEnlD 7"p 7'4.1�) ,a26VEA/7-
1 l 7,1/'/A/ /P OF Fl%//S,4-1 ED (3I0A Z7 ,�20��=1�/niF/L T2<t TinJG
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n(� /� yI Yt✓ M5TO n/GAL�O�/ /N✓Er � .6 J �t�c_
f /ivVEeT CA PA C/ T Y ,4/2 O,UNO
S-�T/G TA
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lNVEZr �
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1 q,-S 74 C� R O u. N L) WA TAR'
L0<fA7-/0/l/
f �A sill"
SEAT/G. TAN.e, �7/ST2/BUT/O,V 80X
_LL�I—.�P_L_�3.1 ____.�_ 1._ 3 Q _/ -�_ ._ • ' �S O U 7`[_ETS� A%V D L�.4 C f✓/.�/G �/T
{
FO,� f '� ?"it��.t'� rLE/NFO.,-CED GOtilCT�'G-TE
j a
3000 �/ M/N.'
(� �� � ff — ff � �- xi.
. 20000
/ ^ 7�/ill_ ,r„_..rJ!{/"1 J r, ��"', "s.✓`'. ..'1 t`.'� ��� -wk �;sx������.s.' 0,. LOAD � - -
J �3E HOC 7-ZED
: lV`� � .: :r' f� :,,`" F ,'} �tf4 , OvZ_.e Sys T�M N- 20
:1 �� R►1Y T}} EX 1'11YGlt: l�€4 _ '1f1� /S USED.
�- r �titN.Dfi W
LOCA —10N 15 CORRECT A 5 5 8U t N A fed!% '���,
17 lC� � ifrt�tY` /�� fist' ` Jei:at'_s ru> --- -----
l QGc!N O I?AR 1V 5 T A L::6
. -�. ,� L�,4 TE NE.Ll LTA•-/ ,�1GE.vT
NOTE: ALL COMPONENTS TO BE
MARKED WITH MAGNETIC TAPE nw f I
RISER COVER TO BE WITHIN G" OR SIMILAR PRIOR TO FINAL
TFF OF FINISHED GRADE BACKFILUNG
TOF = 100.00 9" MIN. COVER TYP. MIN. 1 INSPECTION PORT G"TO GRADE
98.00`+/- WATER TESTED FOR LEVEL F.G. EL: 9G.001 "" `
4" PIPE PVC I
2' LEVEL Rr ��..�
;. EXISTING PIPE BACKFILL WITH CLEAN TITLE V AND
5= 0.02 FT/FT
t 13.0 +}_ LF ?: r:=, d 4"SCHEDULE k.a
,., ? �4t.,, r , .a .
40 PVC PIPE EL.94.08'
5= 0.01 FT FT EFFECTIVE LENGTH 5.Q
VEy }
LIQUID LE L
Q
Ge
S- 0. 15 FTIFf
IO^ I4 20.0 +/- 25.0 +/- LF
LF
*. ,-F.•., t, • LESS 2' LEVEL e • e a m e e e a o a a e e e s o e o e o e s EL.92.75' s -`
PIPE INVERT O . r
97.50 +/- %.99 94,04' RooEND CAP
GAS BAFFLE 93.87 EL.93.G4' _
EX15TING CLEAN TITLE V SAND
PLACE D-BOX ON 6 OF USE 12 INFILTRATOR ARC 3G HC LEACHING '¢
BIJILDiNG 97.24` _ MECHANICALLY COMPACTED EL.88.75' (SEE NOTE 1 G)
CHAMBERS WITHOUT STONE
STONE 2 "ROWS OF G UNITS (30'X2.83 LOCUS MAP")
DISTi�IBUTIC}N H-10 LOADING
EXI5TING 1000 GALLON E30X It, 11, NOT TO SCALE
SEPTIC TANK H- 1 O 12"M
H- 1 O
= I NOTES:
SEPTIC SYSTEM PR.OEILE 1 . VERTICAL DATUM: T.O.F ELEVATION = I00.00' (A55UMED)
NOT TO SCALE 34.5"----►a 2. SEPTIC 5Y5TEM SHALL BE INSTALLED ACCORDING TO 3 10 CMR
15.00 (TITLE V) AND THE TOWN OF BARNSTABLE BOARD OF HEALTH
REGULATIONS.
DATE:JULY 24, 2014 HEALTH DEPARTMENT:DONNA MIRANDY 3. ALL PIPES SHALL BE 4"5CHEDULE 40 PVC
184.71' 4. THE DISTRIBUTION BOX SHALL BE WATER TESTED TO INSURE
N89°43'23'E TEST HOLE f -GSE=9G.5 SOIL EVALUATOR:SHAWN MACINNES
DEPTH FROM SOIL SOIL OTHER LEVELNE55 AND EQUAL FLOW.
n SURFACE SOIL TEXTURE COLOR SOIL (STRUCTURE, 5. THE INSTALLER 15 TO VERIFY THE LOCATION OF UTILITIES AND
(INCHES) HORIZON (USDA) (MUNSELL) MOTTLING STONES,ETC.) SEWER LINE ELEVATIONS PRIOR TO INSTALLATION.
0-4 A SANDY LOAM I OYR 3/2 G. SOIL ABOVE C LAYER(SHOWN ON SOIL LOGS) SHALL BE
c ' REMOVED AND REPLACED WITH CLEAN SAND ACCORDING TO MA55.
CONVENTIONAL S.A.S 4- 22 B LOAMY SAND I OYR 5/G LOCAL 5PECIFICATION5 IN THE 5.A.S. AREA.
` 22- 120 C MED SAND I OYR G/4 7. EXCAVATION FOR AREA WHERE FILL 15 REQUIRED SHALL EXTEND 5'
FOR ILLUSTRATION ONLY-DO NOT INSTALL LATERALLY BEYOND S.A.S.
2-500 GALLON CHAMBERS WITH 4'OF STONE 100 1 2'8X25.'5.A.5 FOOTPRINT 8. SYSTEM IS NOT DESIGNED FOR GARBAGE GRINDER
- ` c
BOTTOM AREA=320 SF --' 9. ALL PRE CAST UNITS ARE TO BE PLACED ON G" MIN. CRUSHED
SIDEWALL AREA= 151 SF -' STONE, MECHANICALLY COMPACTED.
TOTAL AREA-471 5F 10. MIN, PIPE SLOPE 1/8 IN/FT, 114 IN/FT PREFERRED.
TOTAL CAPACITY-0.74 GPD/SF(47 f SF)-345 GPD °
GROUNDWATER ENCOUNTERED AT 93" ELEVATION 88.75' 1 1 . MANHOLE COVERS ARE TO BE WITHIN'0" Or FINISHED GRADE.
PERC AT 3011 - <2 MIN/IN PERC AT 25 GALS. 12. SEPTIC TANK TEE5,5HALL CONFORM TO MA55 4� LOCAL
100___ !� SHED SHED REGULATIONS. _
13. ALL STONE 15 TO PE DOUBLE W45HED ACCORDING TO MASS.
' EXISTING L VG-6F#AM5E�_�.__-__------"""--""��
LOCAL REGULATIONS.
' ABANDON I PLACE 14. GROUND COVER OVER SYSTEM COMPONENTS SHALL NOT
98 EXCEED 3' UNLE55 COMPONENTS ARE H-20.
''wrwl
15. CONTRACTOR TO NOTIFY HEALTH AGENT AT TIME OF
DECK DESIGN CALCULATIONS:
m /� w EXCAVATION TO VERIFY SOIL ABSORPTION MATERIAL 15
0)N NUMBER OF BEDROOMS: 3 SATISFACTORY.
m'm GARBAGE D15P05AL UNIT:NONE I G. CONTRACTOR TO NOTIFY HEALTH AGENT AT TIME OF
BUILDING #972 i Z EXCAVATION TO VERIFY 4 FEET OF SUITABLE MATERIAL BELOW SOIL
LOT 55,732 S.F. / TOTAL ESTIMATED FLOW: 0 10 GAUDEDROOM/DAYX 3 5EDROOM5) = 330 GPD AB50RPTION SYSTEM.
REQUIRED SEPTIC TANK CAPACITY = 200 % = GGO GALLONS 17. CONTRACTOR TO INSTALL INFILITRATOR ARC 3G HC CHAMBER5
98 D-B X TOF = 100.00' ; ACTUAL TANK 51ZE: 1000 GALLONS (USE EXISTING) IN ACCORDANCE WITH MANUFACTURER'S INSTALLATION GUIDELINES
- _ (ASSUMED) EXISTING I OOD GALLION ' AND MASS TITLE V
5H PRECAST Co EA RETE1 c� LEACHING AR REQUIRED:
�\ SEPTIC TANK -10)1
TEST HOLE SOIL CLA55 - I LOCUS INFORMATION
� DECK IN
LIAR- 0.74 GPD/FT.7.
330 GPD/0.74 GPD15.F. = 445,05 5F USE: 44G SF CURRENT OWNER: SCOTT MEYERS
TITLE REFERENCE: BOOK: 20507 PAGE: 332
8• 00 O �- LEACHING CAPACITY: ASSESSORS MAP/PARCEL: 45 - 10
% INFILTRATOR ARCH 3G HC STANDARD TRENCH INSTALLATION LOT SIZE: 1 .28 ACRES
j ARCH 3G HC - 2.83'WX5.0'LX0.89'H FLOOD ZONE: ZONE X
' I UNIT = 5LF X 7.79 SF}LF = 38.95 SF/UNIT
3 'r 'GRAVEL DRIVE 446 SF 138.95 SF/UNIT = 1 1 .45 UNITS- USE 12 UNITS 8}14}'f.4 ADD CONVENTIONAL SYSTEM NOTE PER BON
I T�la
� USE 2 ROWS OF G ARCH 3G HC CHAMBERS Date DESCRIPTION Drawn Checked
TOTAL CAPACITY:2.9 - R E V I S 1 0 N S
' 12 UNITS X 38.95 SF/UNIT = 4G7.40 5F
96 _ 2.8 �/ 4G7 5F X 0.74 GPD/SF = 345 GPD SEPTlC SYSTEM UPGRADE DES1GN
FOR W1 N G COMPANY
S.A.S-USE 12 INFIL TR ; r\ ,AT
ARC 3G HC LEACHING j 972 RI VAT
ROAD
CHAMBERS WITHOUT STONE I N
2 ROWS OF G UNITS
+ H-10LOADING ' 4LZNOI S MARSTONS MILLS
4 ``�` f f �� SHAWN y�s� SCALE: 1" 20' DATE: DULY 3t3 2014
o MaciN�tES '�
v CIVIL `�"
.fl .4132$
SITE FLAN MACINNES CONSULTING
�4v ss II 201 ss orvAt P.C . BOX 1182
EAST SANDWICH, MA 02537
94 (508) 2742091
NOTE: THE PROPERTY LINES ARE APPROXIMATE AND ARE COMPILED FROM PLAN OF LAND IN MAR5TON5 MILLS MASS. IN THE TOWN OF BARNSTABLE FOR DUCK ENGINEER
POND ASSOCIATES TRUST, BY GEORGE LOW 4� CO. DATED FEBRUARY 5, 1979 AND 15 NOT INTENDED TO BE A SURVEYED PLOT PLAN. IT SHOULD BE USED FOR DRAWN BY: 5GM �_
0 PURPOSE OTHER THAN SEPTIC SYSTEM INSTALLATION CHECKED BY: SGM SHEET I OF I