HomeMy WebLinkAbout0981 RIVER ROAD - Health 981 River Road
Marstons Mills P
A = 045 002
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Commonwealth of Massachusetts
Title 5-Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ProT Address �.,.
Owner y�/► /
required on is 975;vk'� /�! s 0 b -O(.it >l �
required for every
page. Cltyfro State Zip Code Date of inspedion:r'
sa
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:when A. General Information
filling out formsf
on the computer,
use only the tab 1. Inspector:
key to move your cA
cursor-do not 'j>t7 a1 5
•keyuse the retum Name of Inspector
>-►n 15 E4i2 Z i- Seg u Ic e
Company Name
I' 7, ed (a A
Com ny Address �b
Cillyfrown State Zip Code.
Telephone Number Lkense Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection.The Inspection
was perform based on my training and experience in the proper function and maintenance of on site
sewage di I systems. I am a DEP approved system Inspector pursuant to Section 1&340 of
Title 5(3 CMR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ N Further Evaluation by the Local Approving Authority
Inspector's signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. if the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original should be sent to the system owner and copies sent to the
buyer,if applicable,and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform In the future under
the sane or different conditions of use.
t6ir�.doc•rev.8H s Title s omaw vopedion Form:$ Sewape Dtsposei syd-•Pape 1 of 17
e
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Rgle t ea
Proper� AR Add
;RIVI�--
Owner Ownaell Name
information is r i f��7-o YES yl�'(.c.� D 76 41g oz� Z/ /00
required for every / /�[&�
kv
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) Syst 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:
) 5;-401L, 01 r0ftlk P--O�
CV
ddd4
glrjo (4m /4 6
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsuiface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
MIA RD
Prop Address
v
Owner Owners me
information is
required for every
page. City own State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Of el Inspedion Form.Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9ill
Po
Prope Address
I C. 90 r
Owner Owners Name
Information is — Mdf S7y1N.7 N&Z S Z/
required for every
page. cityi own State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fall 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 dogged SAS or cesspool
❑ otti�� Liquid depth in cesspool is less.than 6" below invert or available volume is less
than Y2 day flow
t5ins.doc•rev.6116 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
Ill f2 )qp
Pro Address
X ru)to Kt, 1��
Owner Owner's Name y�
information is � C�, 1 f / ,,� q n'/ D �( -Z( /�
required for every 1/' C. LLB UL h c/t
page. cityrrown state Zip code Date of InspeWon
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ❑ ��/4 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ W�� Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ . ❑ IVI 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 chaln of custody must be attached to this forma
❑ 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 wi in 400 feet of a surface drinking water supply
E] ❑ the system i wit in 200 feet of a tributary to a surface drinking water supply
❑ Elthe syste is I ted 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.doc•rev.6H 6 Title 5 official Inspection form:&6swfece Sewage Disposal System•Page`5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
9914 Rivelz go
Property Address
Owner &fC 1�e U
Owner's Name
information is S")� Q y od Z I J�'
required for every Kl[ ,,1 _[__�
page. City own State Zip Code Date of Inspectlon
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
�LVIA��C p�, [ ❑ Were any of the system components pumped out in the previous two weeks?
❑ t[( Has the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
El available
as built plans of the system obtained and examined?(If they were not
available note as WA)
[/ ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
U ❑ 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
El ❑ 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:
2/ ❑ Existing information. For example, a plan at the Board of Health.
Ll/ ❑ 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(6)]
D. System Information
Residential Flow Conditions: _
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): -l'
t5ins.doc•rev.6N6 Tide 5 Offidal hspection Forth:SubeLdece Sewage Disposal System•Page 6 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G81 A Rivea. Kn
Prom&Addre s
Owner Owns s Name
Information Is �{ p�
required for every S GWS �,�I/,L 5 _ �•�Q 2v!& —DcA Z,I 1<'
a
page. Gown State Zip Code Date of Inspection
D. System Information
Description: v
1 JJJ q f.AILA
Number of current residents: 9e1,4-D
Does residence have a garbage grinder? ❑ Yes C2/No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes [ No
information in this report.)
Laundry system inspected? ��❑ Yes ❑ No
Seasonal use? ❑ Yes O/N o
t(�, .- �5-3 G Pl?
Water meter readings, if available(last 2 years usage(gpd)): ao i _ 3 3 3 6 PD
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: 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., c.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank pres t? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 6.system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Prop Address
Owner Owners N me
information is
required for every .4 �7J � �/ o C*
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? IWO 5W. 5-T. LEI Yes ❑ No
If yes,volume pumped: I0ci0 6. 4-
gallons
How was quantity pumped determined?
Reason for pumping:
Type of ystem:
Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6116 Tide 5 Official Wispection Forth:Subswface Sewage Disposal System-Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Pro Address
Owner Owner's Naffle
information is
required for every o C�—�
page. Citylrown State Tip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? El Yes �o
9 9
Building Sewer(locate on site plan):
Depth below grade: feet
Mate ' I 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.):
04 P
Septic Tank(locate on site plan):
ri
Depth below grade: fee
Material of construction:
ncrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age: yearn
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Ofheiet ftpadlon Form:Su!adore Sewape Disposal System-Pape 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
PT' Xddress
AAAAX
Owner Owne s me
information is ,l ��1 /od
required for every '`v �L
page. cityfrown fate Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cunt.) . Sol&, —Fowt
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance fromi 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.):
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 t top of outl tee or baffle
Distance from bottom of scum to bottom f outlet tee or baffle
Date of last pumping: Date
Mns foc-rev.6116 Title 5 Of W hispecdw Form:Subsurface Sewage Disposal System-Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Props ddress
WILe K,L go
Owner OwneZ�&
,��information is j�y/ 02 0S iqC4 z/ /g
required for every
page City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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 doc•rev.6116 Title 5 Of6ael Inspection Form:Subsudace Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title.:5 Official Inspection . Form
Subsurface Sewage Disposal S em Form-Not for Voluntary Assessments
Pro dress
Owner Ownet's e -
Information is f�
required for every ` 3 (2L 2./(9
page, City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids`carrydver, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes .. ❑ 'No*.
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewape Disposal System•Pepe 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Pro Address
All a
Owner Owne?s-Name
information is 1I!' OZL OC4 2-1 /Y
required for every
page. My/Town state Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits number: OY 10Jo G.P
❑ 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.):
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
Nns.doc•rev.61116 To 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
Prop P"i
Address
Owner owners N me
information is � �/ J D Z Oct Z'/ I
required for every ,'f`�
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
-i L. Fat
v�� ph
Cv
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.):
tftsdoc•rev.6/16 Title 5 offiael Inspedlon Forth:Subsurface Sewage Disposal System•Page 14 of V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Prope dress
Owner Owners N e
information is
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at leas two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
wher public water supply enters the building.Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
. G
V
p
2
0 ®4
Al
61 2gp
g 2 y4`
C 2 q8'
t5lns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewape Disposal System•Pape 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 A R 1vef, AD
Pmpe&Address
Owner Owners N me
information is Z l�
required for every A 0Z
page, Cityfrown 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: 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:
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 official Inspection Form:Subsurface sewspe Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
qg�
Prop Address
Owner Owners N4me ¢�,_, �
information is O (�(3 Z r3
required for every
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
(V1 Inspection Summary:A, B, C, D, or E checked
[Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
[�S tem Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t6ins.doe•rev.6/16 Title 6 Oftel Inspection Form:Subsurtte Sewepe Disposal System•Page 17 of 17
c-)L[5- Db
Commonwealth of Massachusetts
Title 5 Official 'Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r-
Properly dress CO
Owner Owners Nne �f/� �yf�
Information Is G�=1 � D Z old � �� a
required for every /�D state Zip Code Date of Inspection
page. Cily/Town i
I yc�
Inspection results must be submitted on this form. Inspection forms may not be altered In,any
w Please see completeness checklist at the end of the form.
Important:when A. General Information i
filling out forms 3 I
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do notes
.use the return Name of
Company Name
o
IP 2, T
Compan Address
.4
Cny/ da vn .
09 4-y J�2�� state 5 I�fi Zip Code
TeWhone Number Ucense Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information repo below is true,accurate and complete as of the time of the inspection.The inspection
was perform sad on my training and experience in the proper function and maintenance of on site
sewage dis systems. I am a DEP approved system Inspector pursuant to Section 15.340 of
Title 5(3 CMR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs her Evaluation by the Local Approving Authority
I rs ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original should be sent to the system owner and copies sent to the
buyer, 9 applicable,and the approving authority.
***`This report only describes conditions at the time of inspection and under the conditions of use
at that time.This Inspection does not address how the system will perform In the future under
the same or different conditions of use.
t6ine.doo•rev.SM S To s owcw mweftn Form:Subsxhm Sewage DlwoW Symm•Page 1 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
LP
Propei%LAddress
Owner Owners NameInIbrmation Is
required for every ' -!
page cty/rown 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:
2r'l 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:
2 S`L) f
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.doc-rev.6/16 Title 5 Offidal Inspection Forth:Subsurface Sewepe Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is ��Q d 2 b y� ac 2-1 I
required for every t
page Citylrmn 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(cunt):
❑ 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 wdhin.50 feet of a bordering vegetated wetland or a salt marsh
tSlns.doc•rev.6116 Title S Official Inspection Form:Subsurface Sewage Disposal system•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owne aarr
information is __J `:LL y�C_. _ G
required for every v 1 � ��2� /D
page. Cityprown 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 N 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' day flow
t5ins.doc•rev.6/1 S Till 5 Official hreped ion Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Properly,ddress
� / 1
Owner Owner's Name '
vk
Inf6riin don is Z;gi2 " d C 7-
required f
for every
page. Cityfrown State Zip Code Date of Inspectlon
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
4� obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑l Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ❑ 1 . Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ❑sPAny 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 collform 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.
❑ ,�]—�,',J The system fail . 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 eith "yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 4 feet of a surface drinking water supply.
❑ ❑ the system is withirt/20 feet of a tributary to a surface drinking water supply
❑ El system is I*ted in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)fir a mapped Zone If 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.
t5lns.doc-rev.6/15 Title 5 Official tnepection Form:Subsurlaee Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
AA
Property Address
17—n' P.0
Ow Own s Name
information is
required for every `,I ��
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
JJ % ❑ 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 WA)
[[� ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
[3/ ❑ Were all system components,excluding the SAS, located on site?
[5 ❑ 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?
Lg' ❑ 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:
❑ [P/ 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(6)j
D. System Information
Residential Flow Conditions:
4
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
15ins.doc•rev.6/16 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 6 of 17
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Najne Information Is L�2GNDr�CI fl Z� U Z
required for every
page. Clty/Town State Zip Code Date of Inspection
D. System Information
Description:
Z
Number of current residents:
Does residence have a garbage grinder? ❑ Yes VNo
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 921"'No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
),o ib - 2 S3 6 A0
Water meter readings, if available(last 2 years usage(gpd)):
Detail: 6YA 614 WM 9q1A 1516
Sump pump? ❑ Yes No
Last date of occupancy: Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatslpersons/sq.ft., etc.):`. :'
Grease trap present? / ❑ Yes ❑ No
Industrial waste holding tank present? / ❑ Yes ❑ No
i
Non-sanitary waste discharged to the-title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5lns.doc•rev.6/16 We 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal
System Form-Not for Voluntary Assessments
t� Fd1
Property dn3ss '
Owner Owners
Informationrequired for every is
„1�•�/�� '''/U' fI�.r; k (7� Z,f l 71
r�
page. Cityfrown 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 inormation:
1416 We-
Was system pumped as part of the inspection? . 150, C4L- 5.T. VYes ❑ No
If yes,volume pumped:
gallons
How was quantity pumped determined?
ow.
Reason for pumping:
Type of yytem:
Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 6 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
Pl� �!
Props Address
Owner OwndYs Name �/f Information is
required for every �'/'/ „/J�,� o Z�y9 p� z:l 1
-���� ^►'T
page. C1W I own State Zip Code. Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
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 tc.):
V C `4
Septic Tank.(locate on site plan):
Depth below grade: feet
Material of construction:
Vconcrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal,list age: year
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc rev.6/16 Title 5 Offidel Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
Property AAdrm
b4lyul -J�
Owner Owners Name nA� �/
i required
on �Yyl�v i -/`lA ��w 0 L 6 y 0 ( ) 1l
page. for every Cityfrown
e State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cunt.)
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.):
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
t5lnsAoe-rev.6116 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Pape 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property ddress
Owner Owner'77&4
///f�
information is �, /���� � 0Zd 9 lrequired for every
page City/Town State Zip Code Date of inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
A4^-
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
i
Material of construction:
concrete ❑ metal ❑,fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
r �
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
t5lns.doc•rev.B/76 Title 5 Official Inspection Form:Subsurface Sewage Disposed System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's N me
106nnation Is
required for every �1�rav
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
D
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
edqan c41A r
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.):
i
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Tide 5 Official hspecdon Forth:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
Title 5 Official
p
i ial Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Props ddress
Owner Owner's NameInfiormation Is �
required for every Gt /To`wn''
paw y State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
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.):
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
t5hre.doc•rev.6/16 TO 5 official Inspeclion Porte:SubsuAaos Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
PmpRAddress
017AuL KLA-,�
Owner Owne ss/Name
infdrmation
i required for every !►"� �'I �� U V Gf ��
page. CitylI own State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
a
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.doc•rev.W15 Title 6 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dispo al System Form-Not for Voluntary Assessments
b
I�
PMDe Address
del
Owner Owner's Nameiftrinadon Is
C)
required for every "�C� d
page. Ci yrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
]Check Slope
❑ Surface water
Check cellar
q,
❑ Shallow wells
Estimated depth to high ground water: 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: Dace
❑ 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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5lns.doc•rev.6116 Title 5 Official tnspec ion Forth:Subsurtece Sewage Disposal System•Page 16 of 17
V
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Dis oral System Form-Not for Voluntary Assessments
Pro Address
Owner owns s 3me
information is �A� { Z`
required for every � "4�
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
[hand-sketch in the area below
❑ drawing attached separately
Cb
3
2
0
0
Al- qD'
6 1 -
8'
i
C � '
6
C 3 - 2z`6"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dis7al System Form Not for Voluntary Assessments
�I
Prop Address /)
R
Owner Owner's N e
Information is Ng
required for every /r J � =L°— o Z b
page Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
1] 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.doe•rev.6/16 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 .
No. )_0® — (]� Fee
THE COMMONWEALTH OF MASSACNUSETTrS
Entered in computer: -10
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Mt.5pooar *p5tem Con!6truction Permit
Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) IB omplete System O Individual Components
7fndress or t No. Owner's Name,Add ss and Tel. o.
oci�-ssap/Pazcel
Installer's Name,Address,and Tel.No. '/ Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Z Lot Size VKW 7Ssq.ft. Garbage Grinder( �
Other Type of Building 7 We No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Ile gallons per day. Calculated daily flow gallons.
Plan Date zOla_3 Number of sheets / Revision Date
Title /l! r7e
Size of Septic Tank / Type of S.A.S.
Description of Soil (J-a
S�
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b s o ofUgialth
L/�3Signed Date
Application Approved by - Date 210
Application Disapproved for the fo owing reasons
Permit No. 6 20 03y06 Date Issued a_> 0
Fee r
t
' \ THE COMMONWEALTH OF MASSACFiUSETT$ Entered in computer:
Yes
. PUBLICS HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for Diopool *paem Congtruction Permit
Application for a Permit to Construct( . )Repair( �)Upgrade( )Abandon( ) LE/Complete System El Individual Components
Locationgd—dress or Lot No. pwnei's Name,Address and Tel.No.
Assessors Map/parcel ,,,f„O�S s�j�/JS
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No
Type of Building:
Dwelling No.of Bedrooms Lot Size 4VW 75 sq.ft. Garbage Grinder(✓�O
Other Type of Building f P1 7<_id I e No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow � gallons per day. Calculated daily flow '2 Z Q gallons.
Plan Date 9'17Cp/0 3 Number of sheets Revision Date
Title I/G'SOD 5�_011
Size of Septic Tank /S� D Type of S.A.S. -7Ca�, - � ��� �' O�6;-Xb
l � l D-a 'L Jos I .2-r,� . �X /3X o
Description of Soil� .SG�C fNvP avv,-1 f v a� f.
5,4
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the a ore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not tofplace the system in operation until a Certifi-
cate of Compliance has been issued b jthis Bo/arid of Health. —_--
Signed v// �' '� Date
Application Approved by n,- Date 01
Application Disapproved for the fo owing reasons
Permit No. 2U°Z - y0b Date Issued CSF=5,2 1
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY, that th On- ite Sewage Disposal System Constructed( )Repaired(✓)Upgraded( )
Abandoned( )by / � G> ! C-i!�1II5 ,
at /�S///2�/, !� "/S 7`/J!�S /S has been constructed in accordance
_ wid the provisions of Title 5 nd t+:e fcr Disposal System Construction Pe=.,:t No.2 60 3- 140 h ,sated P--22-0 3
Installer Designer p
The issuance of.this a shall t be construed as a guarantee that the s stem wi'IQnq BestdDate p Z _ 1e3 g Inspector y
.. �
---------------------------------------
No. <?o u 3— W7 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION . BARNSTABLE., MASSACHUSETTS
Mie;pozal &pgtem Cong4ruction Permit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at / r ✓ � -�'�G '/.S�`G��95 /�9i1�5
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three, qEs_ the date of this-permit.
G/
Date: (� ! Approved by
r
TOWN OF BARNSTABLE
LOCATION «r �o�7;xr SEWAGE#0�
VILLAGE � 1I/f ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /toe Cg G
LEACHING FACILITY: (type) i�j C.rL �fy�..�.� �a� (size)
NO.OF BEDRO
BUILDER O
PERMTTDATE: i?"O- COMPLIANCE DATE: G.. L%
Separation Distance Between the: �t
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(if any wetlands exist 10a O" Feet
within 300 feet of leaching facility)
Furnished by � � "S
CA
o
I
C1' /-7'
50/01
- ..Notice: .This.Form:Is To-Be Used-For--the Repair-Of Failed
Septic Systems-Only --
PERCOLAMN-TEST AND-SOIL EVALUAMON EXEMPTION FORM
I, 6lu E,ffar-el'on av,,OS,hereby-certif3►xhat-the-engineered plan signed by-ate
dated Z- Zd o3 __,�-concerning the-property located at
Izi w . / pv1S frih /d✓f� //� - .._meets all ..of the
following criteria:
* .Thisfalla-spstem-is-connectedto-aresi iat -only.-.T-here.are.no-commercialor
business uses associates with c-chvellmg----
• `lhe mil is classified as CLASS I=ancLdwpercolation-rate-is-_16wd an-or equalto-5-mistrtes-
pe r- inch._Thc applicant may use-historical data-to conclude_this fact-ormay conduct-
-preliminary-tests-at-the site-without-a-health-agent present
• There is increase:in-flow aridtoccTiange-in. wproposed._
• 'there are no-variances requested orneeded.
• The-bottom of the proposedleaching facility will be located no less than five feet above the
• � . -. -
ma adjusted-groundwater table _�Ad�ust-fie groundwater'table usingthe
_Eiino�ptorme�lod-�uheh_applicable:}--
Please complete the following..-
-Aj-Top°ofGrowdSSurfim Blevatiaai�using GIB-iafotmatiot� -- 70
-Bj--G.W.Elevation 4 T +adjuament for high G.W. :Z _ S-S�
DIFFERENCE BETWEEN A_and
.SIG1,tED �)g DATE: d 0
-Based=upon--the-Amm-in&rmation,a repair-permitwRl be-issued for Z-- -bedrooms-
maximum -No-additional bedrooms are authorized in the_ft=without-engineered septic system'
Mdvr-
i LOCATION SEWAGE PERMIT NO.
VILLAGE
i
INS LE '.S N E i ADDRESS
OR OW ER
L
{ DATE PERMIT ISSU
I
DATE COMPLIANCE ISSUED I� � W
-------------
v
v
w. r
� 1
d-
No.. ............ _.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
....................... . ..............OF.............-----.....................------------.......................................
ApplirFation for MipasFal Works Cnnntrar Lion pamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
... ........ .. 7...:fi��... �.NZj a46P ....................................... ------.................----......-•-------
Vff,���� � Loc n-Address or Lot No.
We:. . ........... .. .............
ne
�/ Addre
W •----4i. ....... •.... r ...................................... G�. _ ii'i(�t.. ....... ......._..._.
a Installer Address
Type Building Size Lot............................Sq. feet
V Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ----------------------------•--- .
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacitvj!!QOVgallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...I............... Diameter.................... Depth below inlet.................... Total leaching.area..................sq. ft.
Z Other Distribution box (6-) Dosing tank ( )
Percolation Test Results Performed by................. -•---------••-••-----•••••-----•-----------------••--•-- Date........................................
`Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of
U ---------•----------------•--------------------•---------------------..........
-•------------- ---------------------------------------
•--------------- --------_-----
W •-•-••----•-. '
x Nature of Repairs or Alteratio s— nswer when a cab __ "'�� .-/...... __ _____ __ ____ � ,�G-�'f'
P ------------
P �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by e board o h Ith.
Si ned__ ...._.. 7` ° ........ .... ..
Date
Application Approved BY E = ._. ....................... ...........
Date
Application Disapproved for the following reasons:-------•----•-••---------------•------------•-----------------------------------••-------------•------....._.._
....----•-•---•-•---••--•----•-------•----------------------------------------------------•--..........---------••---------.------•---••----------------------•••-------••-------------------------•---
6—` Dat
. e
PermitNo....................................................... Issued_ ------.....--•-•--V--------- -----.._......_...._.
Date
— - ------------------------------- ---------------- -- ------------------
r
or
No �-a? Fps..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.......................................--------------.....--•---------....---•-•-•--------
Applira Linn for Disposal Works (funstrudion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..: . .! .......................................... •-----.....------•••..----...-•-•--------.
o ion-Address - or Lot No.
-- •............... .............•............................... ................ -- ..... -...- ..
� Add
a - ..................•-----
Instal'er Address
dType f Building Size Lot............................Sq. feet
U Dwelling!—No. of Bedrooms......................... _Expansion Attic ( ) Garbage Grinder ( )
of.o
a persons............................ Showers — Cafeteria Other—Type of Building ---------------------------- N p ( ) ( )
a' Other fixtures .-_-•-----------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/kPagallons Length................ Width................ Diameter................ Depth................
x Disposal'Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.../---------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (v-) Dosing tank ( )
Percolation Test Results Performed by-------------------- --------------------------------------------•-------- Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--- ---- - ---.... --•-•--..•----•-----------------------------------------------------------------------------------------------
ODescription of Soil----`-'^��� `�----=- ---------------••- -----•----------------•----------------------•-------------------------------------------•---------------------
x
1w --------------------------------------•-------------------------------•----------------•---------------------------- -- f 9-
V Nature of Repair or Alterati s— nswer when a ica t `.~ .............
Vic? . ._....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has;been iss ed by he bo rd Ith Signed-- ----- ----- L!
. ----• ---•---•-...---•---------•--••-•---•--• ----• ••-•-••..........._....
Date
Application Approved By--- =r'''d......�'..: :�......................... .........
Date
Application Disapproved for the following reasons:..............................................................................................................
---------------------------------•-------------------------------•-----------.------........-----------•------------------------------.....------.--•-/-......----------------•----••--•-••••....------
Permit No.-•----------------------------------- Issued 1.Q f-- . Date
zN - - - -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tntifiratr of f ompliFanrr
THIS I.S,TO CE TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by..................•= ....... - - ...............................................---------•-••----..P_•...............--•---------------.........----------•-------•-------..•..----
y Installer
has been installed in accordance with the provisions of TITLE of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..............1y_'.._�.u...... dated-................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....................--•-•---•--------------- 2-r�� Inspector............."4- b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH "
No......1 ........I..... FEE..............::......
Disposal arks,QEnnstrnrtion rrntit
Permission is hereby granted............. t. t-5.------'..-•---------•-••-•------------•---------------------- ------................
--...........
•-------
to Construct ) or R pair ( , a Individual Sevl�age_Disposal System
1 -..---•--
at No.. {..
Streetas shown on the application for Disposal Works Constr"uction Permit Dated f _.�...._.. Dated_.._-_�U.'._1 '. ...........
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
Town of Barnstable
OFjME Tp� Regulatory Services Barnstable
Thomas F. Geiler,Directory M
Public Health Division
BA MASS.AS
Ri = Thomas McKean Director
S. q
9$ 1659. `0a' 2007
Arlo . a 200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 4, 2009
Laurie Warren
PO Box 960
Hyannis, MA 02601
As of October 1, 2006 a new rental registration ordinance was put into affect requiring
all property owners of rental units to register their rental units with the Town of Barnstable
Health Division. According to our records, you own the rental property at 981 River Road,
Marstons Mills. (Multiple Units) Enclosed is an application. Please -use a separate
application for each rental unit you own. Should you need more applications, they are available
online at www.town.barnstable.ma.us. Go to .the Health Division page by looking in the
Department Menu. There is a link to the Rental Registration information on the Health Division
page. You may print out as many as you need, and return them to the Health Division with the
appropriate 2009 fees included. This must be completed within (14) fourteen days of your
receipt of this letter.
Failure to comply with this ordinance will result in the issuance of a non-criminal ticket
citation in the amount of$100. Each day of non-compliance is considered a separate offense.
Should you have any questions, please feel free to call 508-862-4644. Thank you in
advance for your cooperation.
Timothy B. O'Connell, R.S.
Health Inspector
Health Division
Direct#508-862-4646
TOWN OF BARNSTABLE
;LWATION �f /'L �' 17� �ofi�rr SEWAGE # O
VILLAGE /�/ /J�f ASSESSOR'S MAP&LOT U -/6.6�
INSTALLER'S NAME&PHONE NO. �d�o�i��
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 12;/ CeL e'za .. (size)
ENO.OF BEDROOM
%UII,DER O O TG'J.u/ape/
PERMITDATE: � -- 03 � C)
COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �f 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 , l� Feet
within 300 feet of leaching facility)
Furnished by
_�ti
f �g
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
u F DEPARTMENT OF ENVIRONMENTAL PROTECTION
d RECEIVED
h
ti
t
W AUG 2 3 2003
0
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 981 RIVER RD MARSTONS MILLS 02648 �1 ®^�
Owner's Name: MARIAN JOHNSTON c�
Owner's Address: 981 RIVER RD MARSTONS MILLS 02648
Date of Inspection: 8/8/03
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA. 02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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 approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally ses
_ Needs Furth aluation by the Local Approving Authority
Fails
Inspector's Signature: ) Date: 8/8/03
The system inspector shall submit a c,py of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
THIS SYSTEM IS FOR THE MAIN HOUSE.THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING
EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.This
inspection does
p o s not address how the system will perform in the future under the same or different conditions of use.
Titles S fmnertinn Fnrm All sr)n o 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
THIS SYSTEM IS FOR THE MAIN HOUSE.THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND
PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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 exiiltration 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: n/a
n/a 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: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ 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 n/a
"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 fi-om pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
I
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
D. System Failure Criteria applicable to all systems:
You mush indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped 5 YRS AGO INFO FROM OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP
certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
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(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered '
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
a
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
Check if the following have been done. You must indicate "yes" or"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 in 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?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the 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 no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) (310 CMR 15.302(3)(b)]
S
Page 6 of 11
I ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):tM d C) ®o 0
Sump pump(yes or no): NO Q \ � �t ���
Last date of occupancy: n/a
COMMERCIALANDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: 5 YRS AGO INFO FROM OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
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): n/a
Approximate age of all components,date installed(if known)and source of information:
1984/ASBUILT
Were sewage odors detected when arriving at the site(yes or no): NO
F
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 6"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: L 8' 6" H 5' 7" W 4' 101",
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle:34"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping:n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of 11
OFFICIAL INSPECT
ION FORM_NOT FOR VOLUNTARY ASSESSMENTS I�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into
or out of box,etc.):
D-BOX WAS VIDEO INSPECTED AND IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
SYSTEM SHOWED NO SIGNS OF FAILURE
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
I
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
i
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
I
Type
1000 GAL 6' X 6' leaching pits, number:
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number:
n/a innovative/alternative system n/a
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure level of ponding, .g Y m dam p g, p soil,condition of vegetation,etc.).
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THE PIT WAS 1/2 FULL AT
THE TIME OF THE INSPECTION AND HAS NOT BEEN MORE THAN 1/2 FULL.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
n/a
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
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.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans'on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER WAS DETERMINED BY HAND AUGER-NO WATER AT 10'
I
it
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL I FFAR :'
, F DEPARTMENT OF ENVIRONMENTAL PR TERt3 2003
d w
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.1
TOWN OF BARNSTABLE
HEALTH DEPT.
c���M Srevee
FAILED INSPECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648 MAR S
Owner's Name: MARIAN JOHNSTON
Owner's Address: 981 RIVER RD MARSTONS MILLS 02648 PARCEL F ® 0 2
Date of Inspection: 8/8/03 LOT l e
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 211.9 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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 approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_ Passes
_ Conditionally ses
_ Needs Furthe valuation by the Local Approving Authority
X Fails
Inspector's Signature: Date: 8/8/03 `
The system inspector shall submit f1submit
py of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspectiIf the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner sha 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
THE SYSTEM FOR THE COTTAGE CONSISTS OF A SINGLE CESSPOOL-SINGLE CESSPOOLS DO NOT MEET
THE TOWN OF BARNSTABLES TITLE V CRITERIA. THE SYSTEM NEEDS TO BE UPGRADED TO TITLE V
STANDARDS.
****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.
Titles 5 TncnPrtinn Fnrm 6/1 5Y 000 1
Page 2 of 1 j
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM FOR THE COTTAGE CONSISTS OF A SINGLE CESSPOOL-SINGLE CESSPOOLS DO NOT
MEET THE TOWN OF BARNSTABLES TITLE V CRITERIA.THE SYSTEM NEEDS TO BE UPGRADED TO
TITLE V STANDARDS.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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: n/a
n/a 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: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of l t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) j
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day now
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped NOT IN THE,LAST YR INFO FROM OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
i
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(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.
d
A
Page 5 of 11.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
Check if the following have been done.You must indicate"yes" or"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 in 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?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up
X _ Was the site inspected for signs of break out"
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the 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 no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5 '
1
Page 6 of 11,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 0 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no):NO
Seasonal use: (yes or no):YES
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: NOT IN THE LAST YR. INFO FROM OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system
X Single cesspool
f",_,"werflow 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): n/a
Approximate age of all components,date installed(if known)and source of information:
OVER 30 YRS INFO FROM OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
i
Page 7 of 11,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
BUILDING SEWER(locate on site plan)
Depth below grade:ON ilo 14
Materials of construction:_cast iron =40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: (locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: n/a
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
n/a
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: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: Na
n/a leaching trenches, number, length: Na
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
n/a
CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 6
Depth—top of liquid to inlet invert: 24"
Depth of solids layer: I"
Depth of scum layer: 1"
Dimensions of cesspool:6' X 4"'
Materials of construction: BLOCK
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
CESSSPOOLS DO NOT MEET TOWN OF BARNSTABLES TITLE V CRITERIA.SYSTEM NEEDS TO BE
UPRADED.
PRIVY: (locate on site plan)
F j
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
i
9 i
Page 10 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
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.
L
I�
�n
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 981 RIVER RD MARSTONS MILLS COTTAGE 02648
Owner: MARIAN JOHNSTON
Date of Inspection: 8/8/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER WAS DETERMINED BY HAND AUGER-NO WATER AT 10'
I
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No-_-d1:.-2C Fxs.:4 ................
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F` !-HEALTH Sa.�� 16
Jdt
._/..�..4J'Yj........----•-...OF................ r Y.�' ........_..... nn
Appliration for Disposal Works Tonstrudion Vamit e XQ Y4.
wr���f• .
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: V�� , �r5
*��
-•Lo io ddress or t No. .
... !' r ...................... .�. n, .. ..............................
••-• --
ner �`_/ _ Address
Installer Address Type of Building Size Lot..../!Ar...........Sq. feet
U Dwelling—No. of Bedrooms.................................Expansion Attic Garbage Grinder)
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
a+ OtUL fixtures .__._
Design Flow....... .. .................. gallons per person per day. Total daily flow.......5..'1..0......................gallons.
f� Septic Tank—Liquid capacity___ gallons Leingth..........._.... Width._..__r_`______ Diameter................ Dep h_____-_.____-_--
w Disposal Trench—No.__.1.............. Width:_l_�2"'________ Total Length.._ ,...._. Total leaching area_ ----------sq. ft.
x
Seepage Pit No.___,`�......... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosin ank
Percolation Test Results Performed by ........................... Date___ 1-�.._ ... �........�
as Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......zdt..........
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
............. •---•----•__-•--
Descriptionof Soil ..... i 1 •-----------•••-•.........................................•--••-•----
ikp
*, ....................I •......
w ...................•--------•-----•---•-•------••--•---•-------•--•-•--•-------•-•----•-•-•.........--•-
UNature of Repairs or Alterations—Answer when a licable._______________________________________________________________________________________________
----------------------- ��t ..---•!.�.1?s �' ---------------•------•-------...----....-•---....-------........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ed b e oa d of health.
V----------------------------------------
----------------------•- •--•-- -••... .._ ••-
/ D to
Application Approved By.... ..
---•---
Application Disapproved for the following reasons:------------------------••-•---•---....-------------•-••---•----•--•-•-....._•-•----•-------•.ate................
...................•--------..._..........------------•------•-•--------------..........----------------._......-------...-------------•---•----....__.....---..---...-•-•----_... ._...__........_
Date
PermitNo.•-------•=--------------------------------------•------- Issued....................................................... ..
Date
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'OCATIO•1 Lo�i .vc.�, Z�ti�,.. NO. 7 v
JILLAGE M1%Ac0_bsroN Nk"c-&. .:.-.. ._ _ DATE
APPLICANT �•�ma�,y;tL l>/�25 c.� FEE
kDDRESS tL�sn�ccai.J(� �, '�A�.►A�.c.w TELEPHONE NO. (Non-refundable
ENGINEER os %,u , sso% TELEPHONE NO.
)ATE SCHEDULED Art,ac.ea
(Applicant' s signature)
. .• ... . O . . . . . . . O O O . . . . ... . . O . . O . . . . . . . . O . . . . . . . O . . . . O . . . . . . . .. . O . . . . . . . . O . . . .. .
SOIL LOG
SUB-DIVISION NAME DATE G �tS �� t TIME 101,to
EXPANSION AREA: YES_y. _NO _ l�1A�: �? _� � ENGINEER
rOWN WATER PRIVATE WELL IZ, BOARD OF HEALTH
EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
tA
5 V►
t.-t
kR!_ 1��
PERCOLATION RATE: ( �� = Z k"
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
3 3
4 �.v-g-� �T 4
5 5
A
8 8
J
9 9 ja.G
10 1.0 w-a AAA-*-
11 11
12 12
13 13
14 14
15 15
16 16
-SUIT�XBLE- FOR SUB'=SURFACE SEWAGE: LEACHING. FIELD _LEACHING PITS_^
- LEACHING-TRENCHES_
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
LOCATION SEWAGE PERMIT NO.
ifp/ &� 4V
VILLAGE
INS. �A LE 'S N E A ADDRESS
, =R OR OWMER
%v, �L
DATE PERMIT I'SSDED �� � ;�/'
DATE COMPLIANCE ISSUED
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SITE PLAN n0 RIVER ' "Marston= Mills" N
na ROA
4 D
014,>
SCALE: 1 =20'
BENCH MARKCOP,NER & COVERED o
m
ASSUMED
V=100.OD' 93 e-
7.6
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STOOP ELE � SITE
177 �
96.02' -
E
Q ,
5� � CK O
1
0
0 : U-
Joshua's
IN-GROUND Pond
9as2 sw7 GENERAL NOTESTESSWIMMING Pool JS
u A 1. ADDRESS: 981 RIVER. ROAD °mestea r
2. ASSESSORS NUMBER: 045002
F
3. DEVELOPER'S LOT:
4. TOPOGRAPHIC INFORMATION WAS COMPLIED FROM AN ...
a � LOCUS
2 ,
ON THE GROUND INSTRUMENT SURVEY. . \
5. TOWN WATER & WELL WATER IS PROVIDED TO SITE & SURROUNDING PROPERTIES, NO SCALE
6. REFERENCE PLAN: PLAN BOOK 325 PAGE 68
93.28 x deoncut 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET OF SAS.
DE K AREA 4Q,= 075t SOFT. 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS.
9 95.84' 1
CONSTRUCTION NOTES i
SHED
i fnotification
r responsible f r
concrete EXISTING � 1-25'l X 13'lN X 1. Contractor is n D gsa e
2.0 D and protection of all underground utilities and pipes.
slab Ek, COTTAGE 1 leaching trench using
0 91.39' t 96.96 FIRST FL. EL.=97.2' g 2. The septic tank and distribution box shall be set
9s.82• X�) crows =vote 2 H-10 500 gal. chambers with level on 6 of 3/4"--11/2' stone.
d„ 935z 4' of stone on sides & ends. 3. Backfill should be clean sand or gravel with no
t q o
96.79' r stones over 3" in size.
L 94.91' ` 0 00 4. This system is subject to inspection during installation
DECK =�P a -J .E by Glen E. Harrington, R.S.
Q) 5. The contractor shall install this system in cccordance
e9s0, psi a c with Title V of the Massachusetts Environmental Code
� toy77. 0 �69s and the Regulations of the Town of Barnstable.
(D o ,t91 6. Provide an Acme Precast 1,500 gal H-10 septic tank, 1 H-10 5-hole D-Box and
0 2 H-10 500 gal. chambers or equal
C) p 7. No vehicle or heavy machinery shall drive over the
DECK septic system unless noted as H-20 septic components.
n p o p 8. Install gas baffle or equal on septic tank outlet tee end.
B, M . 9. All existing inverts and site conditions shall be verified by contractor,
,f DER Pv ' p 9 .6 10. Existing cesspool to be pumped and backfilled.
RO 11. Provide cleonout at bends in main sewer as noted on site ion.
11-61
A P
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EXISTING
DWELLING Des ulations
_
r��T rL...Et.-1°�. - =-- 97.6r
tuR cellar Number of Bedrooms: 2 (EXISTING IN COTTAGE ONLY)
.. ,
Garbage Grinder: NO, GRINDER NOT ALLOWED WITH THIS DESIGN
97.92' Leaching Capacity Required: 220 Gal./Day
Leaching Area Required: 220 Gal./(0.74 Gal./Sq.Ft.)=297 Sq.F-L.
NO. 981 9 .52' grovel driveway Proposed Leaching Structure: 1-251 X 13'W X 2'D Leaching Trench
Leaching Area Provided: 477 Sq.Ft. (3 BEDROOM MIN. PER TITLE V)
Proposed Leaching Capacity. 353 gpd > 220 gpd. rea,'d.
97.90'
c
i 3
n
X
, e 89 9
I X 99.21 0
,D x
3 p
O 1-20•D1h4.ACCESS LAhHME10 -
o O 5,
-3 i )• o �
o_ II
92.41' .
X 96.14'
i 34'
12
4"
X 89.59' .1 STEEL REINFORCED PRECAST CONCRETE
92.61' soil PLAIN VIEW 2 H-10 500 gal. chambers
-'x 94,28' d J -
SECTI01d
�v� S. f
a -
grovel dnv wcy -5371'- Zl END
H-10 500 GALLON CHAMBER
234.75' 9St3' Ou~� Y
_ 1 C N07 TO SCALE
of PoVeme"� �y i k5 Jh USE CME PRECAST OR EQUAL
edge Q 0 -Z 0 OF o
_Y.g PROPOSED SEPTIC SYSTEM UPGRADE
-
1_ t d �t►
C
,_ _ �� � � PREPARED FOR
LEGEND E TO N MARIAN M. JOHNSTON ET AL
r EXISTING LEACHING PIT .1070 AT
0 5 BEDROOM CAPACITY Q
� 981 RIVER ROAD
QI "f E
S �
q Q►
NtTAR BARNSTABLE (MARSTONS MILLS), MA
10' T.
L11
in. from *NOTE: ALL PIPES ARE TO 9E 4" A. SCHEDULE 40 P.V.C.
house to septic tank -NOTE: INSTALL GAS BAFFLE OR EOUAL ON SEPVC TANK OUTLET TEE. �0 EXISTING CESSPOOL TO BE
Septic i3nk coveis must be v e away -i' PUMPED & BACKFILLED
•�-� r oar =,stern=�o s'a PREPARED BY:
_ . . finished hed ode a Y
9
'. within 6 or finished grade 5 HOLE -}-IQ Coto a Existing Grace Etev.=97-955'± PROPOSED ,500 GAL. O/ R.S. `
EX671t AGE 1xsT. ea. T Ts H 10 SEPTIC T ( V N,
� TANK
GLEN E. (�H ACR R I N G
ro wI D-Sox rover must be U n, 2'-t/8"-1/2 1 chcmber cover must be J E D A i \0 J E LAN Cr
;pace waNn 6' of frosted ;;,ad, double ashed stone "it 6" cf finished grade 36 min.
S= 0.02' - 3d•max.
s=.et Level for 2' S-of Too Peastone Elev.=94.50' o o EXISTING
i 101N SEPTIC 0TANKL
55 PROPOSED 75. MARSTONS MILLS, MA 02648
n o 1500 GAL n 13 Inv rt lev.= 4.00'
0 L h V N
o 4 SEPTIC TANK ; DENOTES EXISTING
H-10 P o 000 24 EUN. aottam olLeach X104.46 TEL: 508-428-3862
u ° Gas CR OJALE ' v > d -25' Bench rev.= 92.00' SPOT GRADE
G d LEACH TRENCH 5t ---95-- EXISTING CONTOUR
FAX: 508-428-3862
a
I,
E• CF 3/4"-ll/2"STONE � � y u- .
> a vAdj�sted GY1. 1 - Q' DRAWN BY: GEH AUG. 20 2003
P - APPROX. LOCATION SCALE. 2 ,
f
SYSTEV PROFILE 6• OF 3/-V-11/2•=Tort EXISTRJ, WATER LINE
Not b sale DATUM: ASSUMED FILE: JOHNSTON' SHEET 1 OF 1