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0071 ROSA LANE - Health
71 Rosa Lane Marstons Mills - -- A= 061-058 I i i . Commonwealth of Massachusetts Title 5 Official Inspection Form 1' a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments fit UJ u 71 Rosa Ln .F Property Address PESATURO, JANE Owner Owner's Name `J information is required for every Marstons Mills Ma 02648 1/21/19 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information 614 j354-4- filling out forms on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Q Company Address Cotuit Ma 02635 City/Town State Zip Code reran 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/21/19 I pector'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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts ,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln �V Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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 CM.R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1000 Gallon Poly septic tank as well as a 500 Gallon Pump chamber and two 500 Gallon dry wells 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r ,p Title 5 Official Inspection Form n la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: I 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1' to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln u Property Address PESATURO, JANE Owner Owner's Name information is Marstons Mills Ma 02648 1/21/19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional offic e of the Department.rtment. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? p p . Have large volumes of water been introduced to the❑ system recent) or as art of® this inspection? y y p ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln u Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual). 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 178 GPD 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,�P Title 5 Official Inspection Form 1a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name inormation is every Marstons Mills requiredforeve Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts alp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is Marstons Mills Ma 02648 1/21/19 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Installed 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3.5 p g feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is at normal level t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln V Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �= 5 Title f- � O facial Insp ection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 P 9 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) 10. 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.): Operational as designed * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 - ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): two 500 Gallon dry wells. Test Auger hole into field indicates clean and dry stone 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Ins ection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions, Depth of solids Comments emote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �n 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 1/21/2019 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION 7X Of S-( .L^-- SEWAGE# O�a VILLAGE-OW,-4a/'.-b„"f"-W'lIfASSESSOR'S MAP&PARCEL 6�" S�P INSTALLERS NAME&PHONE N0. SEPTIC TANK CAPACITY G,d h�An, LEACHING FACILITY:(type) nZ NO.OF BEDROOMS 3 OWNER PERMIT DATE: —7--/p COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility a �y Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) i Feet Edge of Wetland and Leaching Facility Of any wetlands exist within 300 feet of leaching facility) o Feet FURNISHED BY .77��/.L �sE Fs is p6 b$ 9"8 G ars http://web.townofbarnstable.us/Departments/Assessing/Property_Values/H Mdisplay.asp?mappar-061058&seq=2 1/2 Commonwealth of Massachusetts ` Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Rosa Ln Property Address _ PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: NGWE at 144" 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: 4/3/2010 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 71 Rosa Ln Property Address PESATURO, JANE Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 Failure Criteria and 6 Checklist completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 a TOWN OF BARNSTABLE O LOCATION �� GAG"�''� `��'' ' SEWAGE# �fQ VILLAGE , i,4a 'l-".IP/211-�'e-rASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. �� SEPTIC TANK CAPACITY �J'T� �®"o�'e���r ����Fiar��cgr� LEACHING FACILITY:(type) ---(size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: ` Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /A Feet Private Water Supply Well and Leaching Facility(If any wells exist { on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) l or Feet FURNISHED BY Z���e"y / � 3 y3 3r� r, No. —�✓ �� Fee (✓ �� ute" r: THE COMMONWEALTH OF MASSACHUSETTS Entered in com P AVO PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes tication for Bis Construction�� oral stem.� p Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ,Individual Components Location Address or Lot No. d?k f'y4 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4</ Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1,0 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .5 c gpd Design flow provided 3 o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /oG'Q 4Type of S.A.S. 3 X s'�o?� ��®.d�'ooqc.af Description of Soil dr 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 Certificate of Compliance has been issued by this Board of th. 21011 4=2 Date 6� Application Approved by _ Date Application Disapproved by Date for the following reasons Permit No, Date Issued - +fir `.�• w .H J , _,. "� . ' � �^ No. C/ t` Fee Entered in com ute• r: 'THE COMMONWEALTH OF MASSACHUSETTS P PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS, yes V0, . ftPrication for -Mis oral 6pstem Construction Vermit. Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System >Pridividual Components Location Address or Lot No. 6,/R&k f'yQ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (50�1 I_cP Lp.-"/" Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 77 Sr 6 d7.7 6/77 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �'1'ioE�CG No.of Persons Showers( ) Cafeteria( ) .1 Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date !;::e— nt—--1a Number of sheets Revision Date Title Size of Septic Tank Gf��-f'Ti— 4!f- /o042 OA'(Type of S.A.S. Description of Soil C o.,. �•e"' �?'cj �'A�,fi., C�A/h�erQJ' 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 Certificate of Compliance has been issued by this Board of th. d o Date �� o Application Approved by Date t Application Disapprov4,by �/ / t, 7 Date i for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repairedd)<) Upgraded( ) Abandoned( )by di/y/ at has been constructed in acco d ce with the provisions of Title 5 and the for Disposal System Construction Permit No ated Installer diry� �cf"l�O�`o/rf j►/c J'c��v�fif Designer OW y/4 4r #bedrooms .3 Approved des ign flq�v ?j�o gpd The issuance o thi§permit shall not be construed as a guarantee that the system on as designed. Date d Inspector 4V - ----------------��--- - --s----------------------------------------- ------ No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Nsposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair Upgrade( ). Abandon( ) System located at �� IF© PA J' and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co 'truFtion 4ust be completed within three years of the date of this permit. - r� Date ' 0 Approved by 1 I. L O CATION S E W A G E PE RMIT NO. PILLAGE I N S T A LLER'S NAME & ADDRESS Jo's e M TA BUILDER ' OR OWNER o e 4 �i DATE PERMIT ISSUED D. AT E COMPLIANCE ISSUED - 177 0, . � / rod p R - No:. .Z'.. Fins..r�.��............. THE COMMONWEALTH.OF MASSACHUSETTS BOAR® "'OF HEALTH -------- ------_........................OF..........................................--.----.----------.........._.........------_--- �- ApplirFation for Diipnoal Works Towi rurtiun Urrmit` Applicatio/ * 4�iereby for P it to Construct ( ) or Repair ( ) an Individual Sewage Disposal System : 1 ... ........... -°--= ---�--- -------------------------------------------- ---...------------------------.........--- ��ovation-Ad----._ams.............. or Lot No. -- . N /. .... .......... •..................................•...............................................__. ...............-----.......----•------•--- . ------ .. Owner Address --•...........................•-•--•--.... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms..__.___i:..:........::.......•....._...._..Expansion Attic Garbage ri p4 Other Type of Building No. of persons............................ Showers Cafeteria ( ) Q' Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter------_......... Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft, Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........ ........... ..................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--••---•----•--------------•-•---•-•-••--•-•----••-••••---•------------.................-•-•-------......................................................... .0 Description of Soil....................................................................................------------------------------------------------------------------......._.....---- W U --- •------------------------------------------------------------ ------- ------- ------------------ ---.------------------------------------------------------------ ••---------------- ------------------ W ••-•••-----------------------------•----•••-•-••--•----------------•--------------------•-••-•--••-----••---•-••---•-----•-•-------•----•-•---------•••••••--- -•---------•--...........-------•-•- VNature of epair or Al erations—Ans er a livable______Gt..� ,..___/^V ...... fir ..-- r.I/�...-- ---- ---• . .................... ..........S--.O.o .,� ------------------------------------ I A t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned f tlier agrees not to place the system in operation until a Certificate of Compliance has been is b the boar of 1 lth. Signed ------ -------------------- ------ ----------•---------------------- --------- ------------•--- ate Application Approved By............ �`Q�•• ---- •... ------ --- ......��"..-2�4_----•...._._.. Date Application Disapproved for the following reasons:-----•---------•------•-----------------------------------------------------•--•-----------------------•...... ----••-------------•---------•••---------.....---•••••--•--•--------•----••-•.••-•----------•-•••-•----•------------••-----•---------•-------•-----------•-------•-•---•••--••-••-----------......----- Date PermitNo......................................................... Issued_....................................................... Date r ' 4+ No' Fxs... ..................... THE COMMONWEALTH O,IE MASSACHUSETTS BOARD OF HEALTH ............. .... .... .............OF.........................----•-.......................................................... Appliration for Disposal Works Tomtrnrtion Farm# Application ereby ade for rPit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ystem a : � / �1 p —` ..Y 7. j__ .. .._...CAI - --- cation-Ad e or Lot No. � Owner Address w3✓�. ...........: . ?.. .e<t rc........ --------------------.._...--------------------------------------------------------........•--••--- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......_.....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of ersons____________________________ Showers — Cafeteria CAI YP g ---------------•------------ P ( ) ( ) Q' Other fixtures ------------------------- ----•- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width--------_....... Diameter________________ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area:.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water______________________-. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --••------------•••--•--•---•--•••••---•••---------------•-•••-.......--••--•--•-•-•--•...••••-•••.....-----••--•---•--•-----•-----•---•......._..•••--_--•-- 0 Description of Soil........................................................................................................................................................................ x U •--••---•--•--••-----------•--•-•-•._...-••---•------------•--•......................•••••••--------••----••-•--•-•------•-•----•-•-•----•-..._...---------•--•-•-------..__...•---•-•--•---•••-•-----_. x -----••----•-----------------------•---------------------•-----------•----------------•-•-•••-----•----••-•---•-----------------•-••••-••---•-•------------•• •--•--•----- ••----•--- U Naor ture f epair or Al erations—Ans er w ap licable.------.G�+ -----ram• ---••- -- •- ----- ------- .................................... ----: ----------------------------___----= Agreem t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned f9fther agrees not to place the system in operation until a Certificate of Compliance has been isswgd,�y the boarcof 1 ith. Signed `= '` ---•-•-•-•• ..... �,, ,3� D to Application Approved By s �__!_ �_.. ' - 1 ..__... c5'�• t ................ f---------y__ Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ .............••-----......-•----------•----------------------------------•-••-•-•----•---------•---•-•---••--•-•--------•-------•--•------•--•---••--------------------•-----------•----••--••-••••••-•- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I.............................................. Trrtifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY-----------------`4 ------ >qil .e...................................................................a___-____-_________-__------_-________-_-______----_--___------------- Inotller at. w w !y1,. �`•'k= --------- = ,....Ef+! -----•----------------------•----•---------•- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..__ ___ _G1__________ dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI,§FA TO Y.. DATE 1:..�.: . iT Inspector............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Pi .......................OF.----....------•---._._.................._..........___......__......._...._. r No. �. FEE... ................. Diolrooal Works Twonstrnrtion amit Permission is hereby granted...........`�--•-"---• PUAA7 Z.................................................................................................... to Construct ( ) or—Repair ( ,)'an Individual Sewage Dis.posal System / at No.............. = ' :::.:......... ... ............,! J a" <r _------...-•-------------.._._..----••- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... -io .___............ o, -r----- ............................................ Board of Health DATE............................................................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS • 3 ,� ar t w Ar � ,^.«_ � ' ;�.: � I RoP.P✓�PYdd�iF cNar9c p'Pa � J , t03At, :.� r, )406 L•pAIL-- ,��,Ri\N 3�p•�� t f s 1-beuS 5Kcrca + i /e60 a/ N.r.s, I 7y, l Sep/• iak ► { � t , T It X / { 75•r•!c e'-Cale,�roH ,` d7� % •/n .��i:�,Or�pSS �I \ / �erc. By �C•M.P.'�rd.-e/9� PST I � �y � f �/>I'°rcv' 6; ./j'oh�:_ mr� f3.0•h! . /8zle t � .• �yers /L1ou�. y{J'/lRE -�/C•yf� 23oYo/f � / �t . ! - �d/•ia�/e!' �s s/crs io i1/.Fifly� w,'��i s l � 1 s for ya.iab/t ltv Cdv�ro// e✓cV171 0a w;A wercrf lee-el e antD/.CA ; ` A w sehar9t 4, t ` With Was�,�d CosSOoo� � G IV bt rrftore,415 NOT To SCALE I � . t ...._. wij Pror.woo 9a1. Grovnd ir/arc/ 5 ap+;c.Tiolc - L���j ��cc.. 4,Si/Cef�C/7 SLiovwin�Prorose4j�/�tf/iot�oT CarrCGt!i%�y e. ;Oi ca�ri�4�-weo� �au/tsf e e s sPoo/�ro 6/eir, e7� Bx.5/i.�/ar dwe dy%�O�L�yC , C✓ ..r•2 �� �°Ce741 oh ftssat a17 e OFIfe a/ ORA p H I4 /dr>lo.Sovrce /��'i� G/ - ��rc�/A3aoo %4` O me NAL EN AWN I' MA 0.17 Barnstable Assessing Search Results y Page 1 of 2 Home:Departments:Assessors Division. Prop(-riy Assessriieht.Se,.,rch Results 7 . . £ ., . =a.i Owner: { SMITH, DONALD D&JANE P P bperty Sketcl$ Legend Map/Parcel/Parcel Extension , 061 /058! j Mailing'Address y � n SMITH, DONALD D&JANE P ( 3 P 0 BOX 264 MARSTONS MILLS, MA. 02648 B VApar,';x j 2005Assessed Values: Appraised Value .Assessed Value �{` Building Value% $67,000 $,67,000 Extra Features: $5,400 $5,400 Outbuildings: $ 1,900 $ 1,900 Land Value: $ 197,600 $ 197,600 lnteractive.Property Map: ap requires Plug in: F> ► Totals:$271,900 $271,900. hhave visited,the maps before 4; Show'Me-The:Ma ( �: p, , April 2001 photos available Sales History: Owner: Sale Date Book/Page: Sale.Price', SMITH, DONALD D&JANE P 4/15/1983 3718/305 $0 2005 R AL,.ES T ATE Tax Information: Tax Rates- (per$.1 000 of Valuation) Land Bank Tax $49.35 Town Fire District Rates _ Other l $6:05 Barnstable Residential $2.12 Land B. Barnstable Commercial $2.80 C.O.M.M..FD Tax(Residential) $274.62 C.0 M:M,; All Classes $1.01 Cotuit FD° All.Classes $1.28 Town Tax.(Residential) $ 1,645 M Hyannis"-:Residential $1.52 Hyannis-Commercial $2.39 W Barnstable;Residential $1.44 W Barnstable Commercial $2.10 Total: $1,968.97 Due to rounding differences theseYvalues may vary http //www town.bamstable.ma:us/tobO2/Depts/AdministrativeSery ces/Finance/Assessing... 9/27/2005 Barnstable Assessing Search Results Page 1 of 2 r 4. i " Hame: Depaitrnents.Assessors Div�siar Property Assessm ntSearcH Results f S Owners w SMITH, JANE P TR Property Sketch Legend Map/Parcel/Parcel Extension 061 /013/ Mailing=Ad'dress i 2 r 1Ti SMITH,JANE P TR E ROSA"FARM REALTY TRUST I P O BOX 264 MARSTONS MILLS, MA. 02648 ! Y n LO2005 Assessed Values: Ji1I,, Appraised Value Assessed Value,-` T - Building Value: $ 125,000 .$ 125j000; Y. 4 •..E;wy . Extra Features: .$2,300 -$2,300 Outbuildings: $5,600 $5,600 Land Value: $ 196,400 $ 196,400 Interactive Property Map: Ma requires Plug in: , 13� ' Totals:$329,300 $329,300 I have visited 4he maps before s - Show Me The Map April.2001 photos available Sales'History: Owner:. Sale Date Book/Page:;. Sale Price SMITH,JANE P TR r1/29/1999 12028/301 $ 1 -% F„*• PITTENDREIGH; FRANCES R DONOR 8/13/1997 10897/091 $.1 PITTENDREIGH, FRANCES R TR 11/15/1 983 3923/298 $0 ''`v`i- ii$l ROSA, GRACE A M-792 8124/089 $ 1 2005 RE L°ESTATE Tax Information: Tax Rates: (per$1 00 Of VaAlaticlll) Land Bank Tax $59.77 Town Fire District Rates Other I $6.05 Barnstable Residential $2.12 Land B. Barnstable Coriimercial $2.80 C.O.M.M: FD Tax(Residential) $332.59 = i C O M.M. AIIlClasses $1.01 Cotuit FD'-AII'Classes $1.28 �j Town Tax(Residential) $ 1,992.27 Hyannis-'Residential` $1.52 Hyannis Commercial $2.39 W.Barnstable=Residential $1.44 W Barnstable-to,mrnercial $2.10 SE http://www.town.barnstable.ma.us/tob02/Depts/Administrdti.ve,Services/Finance/Assessing... 9/27/2005 Barnstable Assessing Search Results ja " Page 2 of 2 Total: $2,384.63 `Due to rounding differences;these values may vary Land and Building Information Land Building Lot Size(Acres) 2.19 Year Built;` 18001 Appraised Value $ 196,400 Living Area r 1603= 4.. Assessed Value $ 196,400 Replacement Cost'$-166,643 f Depreciation " 25''' Building Value" '125;000 Construction Details Style : : Cape Cod Interior Floors CarpetPine/Soft Wood' Model Residential Interior Walls', Plastered Grade Average Plus Heat Fuel Oil Stories ` . 1 Story F A Heat Type Hot Water Exterior`Walls Asbest Shingle AC Type None Roof Structure Gable/Hip 'Bedrooms 3 Bedrooms .r Roof Cover Asph/F GIs/Cmp Bathrooms 1.1/2 Bathrms Total Rooms 7'Rooms x Extra BdIl ling Features ` 'x Code, Description Units/SQ ft . Appraised Value ,.Assessed Value FPL1 ;Fireplace 1 -$2,300 t $2;300� FGR2 Garage-Avg 336 . $5-1600 f '' $5,600 µ`a Property Sketch Legend BAS First Floor, Living Area FST Utility Area (Finished Interior) `rUAT -Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS' HalfiSto,'ry(Unfinished) CAN Canopy FUS Second Story Living-Area (Finished) UST Utility Area (Unfinished) FAT Attic Area(Finished) GAR. Garage UTQ Three,Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO' Patio• ` -'UUS 'Full Upper 2nd Story(Unfinished) FHS Half Story (Finished) SFB- Semi,:Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS.Three'Quarters Story(Finished) y iw �r http://www.town.barnstable.ma.us/tob02/Depts/Administrative S ervices/Finance/Assessing... 9/27/2005 Barnstable Assessing Search Results s Page 2 of 2 Land and Building Information Land .Building- Lot Siie(Acres) 2.68 Year Built 1940; Appraised Value $ 197,600 Living Area,: �510 Assessed Value $ 197,600 Replacement Cosi�1 89;273 Depreciation, 25 Building:Value, 67,000 Construction Details Style Ranch Interior Floors CarpetPine/Soft Wood Model Residential Interior Walls: Drywall ` Grade 'Average Minus '-'Heat Fuel ":'.Electric ` Stories 1 Story Heat Type 3`Elec Baseboard Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip ''Bedrooms 3 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 1 Bathroom a. Total Rooms 5 Rooms Extra Bdtlding Features Code Description Units/SQ ft Appraised Value Assessed Value SHED Shed 240 $ 1,900 '.$ 1;900'., BFA Bsmt Fin-Aver 484_ $5,400 $5;400-- Property Sketch Legend y Y' w BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area (Finished) UHS'"'Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) -'.UST• Utility,Area (Unfinished) FAT Attic Area(Finished) GAR Garage UM Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full.Upper 2nd Story(Unfinished) FHS Half Story (Finished) SFB Semi Finished Living Area WDIK,Wood-Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.barnstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing... 9/27/2005 Apr 09 10 02: 27p Colleen Mason (508) 833-2177 p. l :. in Town.of Barnstable _ Regulatory.Services Thomas F.Geller,Director Public Health Division Thomas.McKean,Director 200 Main Street,Hyannis,MA 02601 Office:508462-4644 Fax:508-790-6304 Installer&Designer Certification Form Dat, -0 Sewage Permit# ®i ®�'PAssessor's MaplParcel Designer: 11Ay 1p ;5• tqwL�lInstaller_ -E Address: G. J �w�� . ►�i Address: C �l On � 7 /a [.L.t was issued a permit to install a (date) (' Z septic system at based on a design drawn by Vl ladtlFESS / ! i aced G2'f!/. esigne ) I certify that the septic system referenced above was installed substantially according to the design,which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e.greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations.Plan revision or certified as-built by designer to follow. i . -�yXOF& 1 Staller's Slgnatur WiI r_: MASS:;�'• (Designer's ignature) (Affix Des-j�ef-s�Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.THANK YOU. Q:Health/Septic/Desiper Certification Form 3-26-04.doc t t oar Town of Barnstable P# ( Xg 7o cI, Department of Regulatory Services MAU Public Health Division Date 3 17 0 h� 200 Main Street,Hyannis MA 02601 Date Scheduled J /® l Time Fee Pd. Soil Suitability Asses ent for Sewage Disposal Performed By: Witnessed By: LOCATION& GENERAL FORMATION [NEW Address '/ �a�� y r� Owner's Name (J-'/.�riFf" �f``j•J��-,� Address s Map/Parcel 6/ C. $`" �/'J Engineer's J,' NSTRUCTION REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body—ft Possible Wet Area —ft Drinking.Water Well --_ft Drainage Way ft ' Property Line —_.ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes �f I t a etlands in proximity to holes) I 1 i 1 1 Parent material(geologic) eb� / f� 4thdr6Ck Depth to Groundwater. Standing Water in Hole: m Pit PhEstimated Seasonal High GroundwaterDETERMINATION FOR SEASONALWATER TABLE Method Used: Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in. Depth to soil mottles: in Index Well# Readingin Groundwater Adjustment f[. Dale: Index Well level , Ad).thetor j Adj.droundwater Level_ PERCOLATION TEST Date Time. Observation I Hole# Time at 4" Depth of Perc _-- Time at 6" Start Pre-soak Time @M Time(9"-6") End Pre-soak, _ — Rate Min./Inch . Site Suitability Assessment: Site Passed Sitc Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q MPTICIPERCFORM.DOC DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselq Mottling (Structure,Stones,Boulders. Con i tent Gravel) l 23 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other', Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders. Consistency,%Gravel i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con iste Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Flood Insurance Rate Map: Above 500 year flood boundary No_ es Within 500 year boundary I r✓ Yes Within 100 year flood boundary No Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviou t rial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on lDLtalProtection (date)I have passed the soil evaluator examination approved by the Department of Env-iron en and that the above analysis was performed by me consistent with the required training,exp se a pe fence described in 310 CMR 15.01 . Signature Date ' 5 �bjD Q\\ EPTICWERCFORM.DOC ' ASSESSORS MAP : O LOGS *_ TEST HOLE -,� PARCEL: ;; - __:. ,_- __ __ _.____ . _ __.______..__.--_ .__._- NOTES: .FLOOD ZONE: � ��9j,i� �r l _ _ SO I L EVALUATOR:. 1 VI I Geri` i ZD Z . . W I TNESS V, REFERENCE�� b�. - � � .�_.� �,...__ __._ _ . � :,/.._� _ .__ DATE: Z 2� 1) The installation shall comply with Title V and Town of Barnstable Board of .� PERCOLAT I RATE: e 2 . 1uj•' Health Regulations. � Sa 2) The installer shall verify the location of utilities,sewer inverts and septic 121-A components prior to installation and setting base elevations. Q TH- t ' �TH-2 3 All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" ) gr Y P P P g per foot. The first r /� two feet out of the d-box to the leaching shall be level. p 8+ ►� 4) This plan is not to be utilized for property line determination nor any other 1D�tM � � 6 purpose other than the proposed system installation. D $ � �► 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. ry . LOCAT.I ON" N MAP 7) The property is bounded by property corners and property lines. a ';' aFi, LSt 8) The roe owner shall review design considerations to approve of total . . '�^l property�Y � PP design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall F- . ^ be removed along with contaminated soil and replaced with clean sand per l 3 _ C�� '�.�Z.. - Title V specs. t b lOf tfr t .. ,9 - ) o oline. Sewer lines crossing the 10 System c mponen s t e feet from water �` SEPTIC SYSTEM DESIGN water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being pp p p g installed below thewater service ,1 line' The line is to be sleeved as aforementioned and maintained in lac } FLOW ESTIMATE place. � l 11) If a garbage grinder exists it is to be removed and is the responsibility of the frry�(�^ ate ��a %��• , ` , owner to ensure such. BEDROOMS AT I GAL -JGAL/DAY ^ -- - 12)The installer is to take caution in excavation around the gas line if such exists. ^ SEPTIC TANK 13)The installer shall verify the location, quantity and elevation of the sewer ... 1 lines exiting the dwelling prior to the installation. 1 GAL/DAY x 2 DAYS - GAL USE I GALLON SEPTIC TANKC -Tt 1�r-1iC SOIL- ABSORPTION SYSTEM SIDE AREA: X _ � - I X 0�7 - �(�1� Z- BOTTOM AREA: Z„ 2 �'�'' D ► lw3 sbN m� ct P I C S Y S T E M SECT:I O N kij �r 40 -- � ---- e d 45 ►� = 1 GAL .157 t .} 1yy ' SEPTIC -TANK �: � � � -. � G�.t+�.'1k� Ge�l'+�f. --�. "• �.'� I as - � 2 hN44wnw4c JOW - SITE AND SEWAGE PLAN LOCATION : � - : PREPARED FOR "� �- E W gt`' a G� yVrt SCALE :25I _. _._..__ - .. M -- --vim.- DAV i D B . MASON R DATE B t� - - --- u---�_ �-- DBC ENV I RONMEWAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA W ( 508 ) 833- 2 177 Z