HomeMy WebLinkAbout0121 ROSELAND TERRACE - Health a,
1_42,1•ROSELAND TLRRACE, M. MILyL
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TOWN OF BARNSTABLE
LOCATION �� � � �� T � SEWAGE#
VELLAAGE 4QJ/LA'S i %� ✓ �� ASSESSO� MAP&L TZ4j�2 f �y
NAME&PHONE NO.'D/7/7 '7 C �J1 T 416e- ,p
SEPTIC TANK CAPACITY VW • , 22,
LEACHING FACII.TTY: (type) (size) J �"
NO.OF BEDROOMS
BUILDER O
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility z�20 / 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 f Teaching ility). Feet
Furnished by } �
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LOCATION d�. ���• SEWAGE #
VILLALiE ✓�• /H�I IS ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY OW
LEACHING FACILITY: v1� �X(0 1— (size) �b
(tYPe)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facility) J Feet
Furnished by �n Spe v 001 �• F���+
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TOWN OF BARNSTABLE p
LOCATION LaIL�4h� �t''. SEWAGE#
VILLAGE 10,47254015 ASSESSOR'S MAP&LOT 5-
INSTALLER'S NAME&PHONE NO. 1/Yl► dim b�r' So t'l �1°1C
SEPTIC TANK CAPACITY _J o nn
LEACHING FACILITY: (type)c;2 21-W5 (size) 10(!X!;)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: a -1-2 - 99 COMPLIANCE DATE: f — 6 e��
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No. y Fee 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipprication for Migpool *pgtem Construction 3permit
Application is hereby made for a Permit to Construct( )or Repair NX)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
121 Roseland Terrace Lot 16 G. Strathie
40 Lauren Drive Marstons Mills MA.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
J.P.Macomber Jr. 508-775-3338 J.P.Macomber & Son Inc.
Box 66
92632
Type of Building:
Dwelling X No.of Bedrooms 3 Garbage Grinder�0)
Other Type of Building ® No. of Persons U Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 660 gallons.
Plan Date 12/5/7 8 Number of sheets 2 Revision Date 1 2/2 7/9 5
Title
Description of Soil Lan 2i,h gni 1 2 _ 5 t Goarce sand & gravelTMedlum sand
6 . 1 Ta-,t, hale 51/22/78
Nature of Repairs or Alterations(Answer when applicable) Adding additional 1000 gallon
leaching 1pit to an existing tank hex Ft nit 1 00% RxsjlRn.inn qrp..R
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 this Boarfi of Aalth.,
Signed wlea Date 1 2/2 7/9 5
Application Approved by
Application Disapproved for the following reasons
Permit No.T/.� Date Issued
---------------- — — - -- - ----- —s
t „wiy�.. - '4 „, .,......-._ a ..-:y{�+- ��.. ��.a ..�,-. .. .. •� �.•. . - .`i .....2 r+_ r�L .-«. - -, -.,..- ,
No. Fee '„T00
1
THE COMMONWEALTH OF MASSACHUSETTS i
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for.Mttpozar *pttem Conotructtou 3permit
Application is hereby made for a Permit to Construct( )or Repair KX)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
121 Roseland Terrace Lot 16 G. Strathie
1V 40 Lauren Drive Marstons Mills MA.
B
staller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i comber Jr. 508-775-3338 J.P.Macomber & Son Inc.
Boxox 66 66
--X, r l
Type of Building:
Dwelling X No. of Bedrooms 3 Garbage Grinder!jo)
Other Type of Building U No. of Persons 14 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 660 gallons.
Plan Date 1 2 5✓78 Number of sheets 2 Revision Date 12/27/95
Title I
Description of Soil T,nam ;vh ani l 2- 5 1 Coarse sand & grwrel 3 1 ma3ium sn"d i
6. 51 Test hole 5122/78
Nature of Repairs or Alterations(Answer when applicable) Adding additional 1600 gallon P
leaching bit to an existing tank box & pit, 1007 Pxananaian, Arpn
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 by this Bo of Iealth.
Signed ► Date 12/2 7/9 5
Application Approved by _
i
Application Disapproved for the following reasons j
Permit No.T Date Issued 62
i
-----—_______—=
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(XX)Con
12/27/9,ri by J.P-Macomber Jr. for 121' o9p1X3d Terracgr
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Z�_dated
Use of this system is conditioned on compliance with the provisions set forth below:
i
No. Fee $30. 00
w
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
a
Mi!gpogal *proem Conftruction i3ermit
Permission is hereby granted to J.P.Macomber Jr.
to construct( )repairy(XX)Yan On-site Sewage System located at 121 Roseland Terrace Marstoms
Mills,Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: '& ' 7[� Approved by .�
New Pit
Existing Leach
Existing 1000 tank.
r
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, Joseph P. Macomber Jr, hereby certify that the application for disposal works
construction permit signed by me dated 12/2 7/9 5 , concerning the
property located at 121 Roseland Terrace meets all of the
Marstons Mills ,Mass .
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGINTI) : DATE: 1 2/27/95
LICENS SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed stem. Also if the licensed installer osesses a certified lot plan,
P P P SY P P P >
this plan should be submitted].
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SEPTIC SYSTEM MUST BE
INSTALLED IN COMPLIANCE., �--�-
No.7 �
. '� Fim.....�.:..............._
~� V41TH ARTICLE II STATE
pTHE COMMONWEALTH OF MASS�AGlVllPTODI_ AND TOWN
BOARD OF HEAL M-IONS° -,-._ -
`� I ... ... _.-..... OF.s��� �J3 4'E.................................
Appliratiuu -fur Biipuuttl Works Towitrur'ti on Vrrmft
IApplication is hereby made for a Permit to Construct (/f or Repair ( ) an Individual Sewage Disposal
System at:
/% !RS7��/.5---/�%,....��5-----------------------------------------
oca o -Ad ess or Lot No.
caner A re
.44
� Installer Address !
UType of Buildi g Size Lot_��.. _______Sq. feet
Dwelling�No. of Bedrooms.-__._-_--3-----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Pa Other fixtures --------------- ------•------ .. .
W Design FlowJ./Q_-!X_,_3-----------------------gallons per person per day. Total daily flow-------_ 30.---:--.._----..-----..gallons.
WSeptic Tank-k iquid capacityfBMgallons Length----------------- Width......---------. Diameter_-_.--.-.--__-_ Depth_---_----.__._
x Disposal Trench—N,o--------------------- Width----._.............. Total Length-------------------- Total leaching area.............-------sq. ft.
Seepage Pit No------/------------ Diameter_----:19'_-�...._. Depth below inlet.................... Total leaching area..___-...__..____.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date_c M '..___...--.
a Test Pit No. 1......11-----minutes per inch Depth of Test Pit---I _ ........ Depth to ground water,N`04!v6-_--_.
LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_.-.-_-_-------.--...-.
-----------•-�---------------------------------------------------------------i.....................---••-----••--•-------------------------------•---••--.
Description of Soil (9-„ ��� `5�.... -. _` �/ zSvfL °`4'. `. .... 1�f9s �✓d1 / o'.....
V ------ ' �. �/ e$' ` I`2 ,D�....r4 ---------------------- -------- -----------------
W ---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable.------------------------------------------------------------------------------------------_---
---------------------------------------------- -----------------•--------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by the board alth.
/ �� ate
Application
A A
PP roved By.---- -
1. _-J_. e
Date
Application Disapproved for the following reasons:.___
----------•-----------------•---•-------•-----------------------------------•------- -------------
---......---••..............•-------•--------------------------------•-••------------.................................................... ...-••-----..........---•--------........._...-----•--.-----
Date
PermitNo........................................................ Issued-- ----------------`-------------------------•--•-•--
a d.
Date
ot;..... s • F' --:�-
N ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'. ..._.._.OF,IB/ �' �' -.........................
Apphratiuu -fur Uiupuutti Worko Tomi#rurtiuu Vrruift
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
Lot No.
oca io .Address ---••--------------•--•---•- oL_F7 ^_...._....
Ownnellr��ff �� A r s w
a �----44�9_, r. L.& --------------------------------
Installer Address
Type of Building A Size Lot_ca�0/-�f_t___Sq. feet
Dwellingle No. of Bedrooms-_-_____�____________________________ Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.-_________________-____-__ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
W ' Design Flow.11.40.1.,3....................... per person per day. Total daily flow-------3i 33 ------------------------
WSeptic TankkL,iquid capacit)4 _gallons Length---------------- Width-------......... Diameter---------------- Depth-.-------------.
x Disposall,4T-rench—No_____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
3 _•Seepa"ge Pit No-----/............. Diameter...... Depth below inlet.................... Total leaching area.-----------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b ____________________________________________________ Date .�_-Ay7r_
Test Pit No. I__.__eA------minutes per inch Depth of "Pest Pit_-/,w2___.......... Depth to ground waterA-_-'0�e_.__-__-
(4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
-----------------------------------------------------------------------------a .. ----•-•-••-------- ----------- -
0 Description of ..... ".r- "-- — COAOI_...54WAD AtV-0 __
w6�1?AJVE-4 -'-•••-/��`�" �A�,�----- -------- --------- ------- - ------------------ ---------------- ---
x ------------------------- ------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable____________________________________________....................................----------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------- ------
Agreement:
The under"'signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by the board alth.
FSi� - -- --- ----------- ....... ---------
f jOate
r
Application Approved By`-"-- --- t�''�� ----------------------------- ---�� ':�r-,7-•-----
Application Disapproved for following reasons-------------- ------------------------------------------------•-----------.._.__.---------Dd2e•••••----•----
•--••-••••--•---------•-••-••....-•-•-••••-•-•---------------••••••------•--•-•-••-••--••---•---•----•-•----------------•--•.....•••••-••-••---••••••---•------•----•••-•-------•------•-••-------------
Date
PermitNo......................................................... Issued........................................................
Date
.rc
THE COMMONWEALTH OF MASSACHU°SETTS
BOARD OF HEALTH
mu.,rdifiratr of Tontphattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 4--or or Repaired ( )
by---... AHW--------A-4-4.'/"7.22............................................
Installer
at-•�-•0-7--*110------V-5 --- _/ / l r- ,,�`` � 1 n� r 1`- `
has been installed in accordance with the provisions of cle<I of The State Sanitary Code as described in the
application for Disposal Works Construction Permit 114W. _1---------------------- dated_ - - ...................
THE ISSUANCE OF THIS CERTIOICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
j
DATE.............. -• ................
( = Inspector
M
THE COMMONWEALTH OF MASS CHUSETTS
BOARD OF HEALTH
sic00A.".......... . ...OF.. Af-:'NS7.*?c.6 --.----.---.-......._.......-......••--------• •
BisVuiitt1 Workp C ontitrur# uit Vrrmi#
Permission is hereby granted.--- _ {/ AAA-- --------------------- ----••---------------.....-------•--•-•------•••--•---••-••----...•---
to Con truce or Repair ( ) an Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction rmit _________ Dated_/;?-- J2_r7,¢--!--------------
' f
DATE Board o
-------- --- ------�-'-- --------------...-•••••••----------
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 7
DEPARTMENT OF ENVIRONMENTAL PROTECTION `/ /
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 121 Roseland Terrace
Marstons Mills, MA 02648.
Owner's Name: Ann Goulart �� ��9�
Owner's Address:
Date of Inspection: July 14, 2005
�.3
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford ¢ =�
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049 co
Telephone Number: (508) 862-9400 —
M
CERTIFICATIONSTATEMENT
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 CAM 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails 4
Inspector's Signature: Date: July 20, 2005
The system inspector shall submi a opy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completin is 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 report only describes conditions,at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 121 Roseland Terrace
Marston Mills, MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Ili
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 121 Roseland Terrace
Marstons Mills. MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
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
"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:
3
Page 4,of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 121 Roseland Terrace
Marstons Mills, MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"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 ''/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 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 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 System:
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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 121 Roseland Terrace
Marstons Mills
, MA
Owner: Ann Goulart
Date of Inspection: Julv 14, 2005
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks ?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the_ p 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:
Yes No
✓ _ Existing information. For example, a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 121 Roseland Terrace
Marstons Mills. MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n1a [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)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 3 vears ago-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
A new pit was installed in approximately 1996-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 121 Roseland Terrace
Marston Mills, MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 2'
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Cement tees were Present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage.
The outlet cover was 5"below Qrade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Continents (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 121 Roseland Terrace
Marstons Mills. MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
f
Page 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENT
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 121 Roseland Terrace
Marstons Mills, MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 zaL)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Commnents (note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
The new leach nit had Y ofliquid on the bottom The scum line was at the sane level The bottom to grade was 9' The cover
was 16"below grade. The older pit was dry The bottom to grade was 9' There did not appear to be any signs of failure
CESSPOOLS: None (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 o:cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY: None (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.):
9
i
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 121 Roseland Terrace
Marstons Mills. MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
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.
8
o a.
Q
3
3 S I 53
s Ya 3
10
G
Page 11 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 121 Roseland Terrace
Marstons Mills. MA
Owner: Ann Goulart
Date of Inspection: July 14, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40+/- feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps, the maps were showing approximately 40'+/-to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
_ V
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: /,,,? r
- � r'c� 1776r-3 Dien �J.
Date of Inspection: Inspector's Name:
Owner's Name and Address: ��
CERTIFICATION STAT .MENT!
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal systems. The System:
Passes
Conditionally Passes
Needs Further Ev luation B e Local Aproving Authority
Fails
Inspector's Signature: Date: / �'-�
The System Ins "y Inspector shall submit copy of this inspection report to the Approving au `' thii'y
ty(30)days of completing this inspection. If the system is a shared system or has ad s'
gpd or greater,the inspector and the system owner shall submit the report to the r riate region � d
office of the Department of Environmental Protection. The original should to thNrA
towner`
and copies sent to the buyer, if applicable and the approving authority.
.
INSPECTION SUMMARY: �9
91
A)SYSTEM PASSES:
I have not found any information which indicates that the system viola riy,of a failur
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated=are4ndicat
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due N1:.., ,�';,
t to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box_. The
system will pass inspection if(with approval of The Board of Health):
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE 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. 1
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER '?
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
Fsr
ENVIRONMENT: aw
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply. '"'
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well. '
The'system has a septic tank and soil absorption system and is within 50 Feet of a private '
R water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
. bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less #t�A
than 5 ppm.
D SATEM FAILS: aY
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
shou,)d be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool. 1�
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
k !f
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 '?wi
pipe(s). Number of times pumped
J'
' litJiir
e
f
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (coutimied)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the followingF";
conditions exist:
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.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
As-built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
,-The site was inspected for signs of breakout.
,--All system components,excluding the Soil Absorption System, have been located on site.
t,/fhe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- +'
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, r'
depth of sludge,depth of scum.
G/The size and location of the Soil:Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3
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1
i I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL
Design Flow: allons Number of Bedroocns:�_ Number of Current Residents: cZ-r�
Garbage Grinder: 0 Laundry Connected To System: F?S Seasonal Use: d f
Water Meter Readings,if available:
Last Date of Occupancy: T___6,-ne v�
sa
COMMERCLALlIND iSTRLAL:%/6
Type of Establishment: `
Design Flow: gallons/day Grease Trap.Present: (yes or no)
'4
Industrial Waste Holding Tank Present:
i
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy: �r
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION `/✓' _,� ,/�
PUMPING RECORDS and source of information // r4r) iYi �G IC�0'
System Pumped as part of inspection: If yes, volume i limped: gallons
Reason for pumping:
TYPE OF SYSTEM:
ZSeptic Tank/Distribution Box/Soil Absorption System
Single Cesspool
r r'
Overflow Cesspool ;fi
Privy
Shared System(If yes,attach previous inspection records, if any) a*f
Other(explain):
,kPI)ROXIMATE AGE of all components,date installed(if known)and source of information:
KlOrb I&Y V 's lei :° >n-
Sewage odors detected when arriving at the site:
f7 Z:
4_ >a��
0l`
,
I "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: C�
Depth below grade: Material of Construction: V-60'ncrete metal FRP Other
(explain) —
Dimisions:_ Sludge Depth: rt/7nP Scum Thickness: Iralle
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage, c.) J'-/S a
?Ni f P j7
s
GREASE TRAP:
Depth Below Grade: Material of Construction: concrete metal_FRP_Other
(explain) t+,:',
Dimensions:
Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:" /C 6
Comments: (note if level and distribution is equal,evid ce of solids carryover,evidence of leakage into
or out of box,etc.) icy
��/ �,
-17
r
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
.t;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM (SAS):���
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive `:
methods) If not determined to be present,.explain:
Type:
Leaching pits, number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields,number,dimensions:
Overflow cesspool,number.
Comments: (note condition of soil, si s of hydraulic failure level of pond'n condition of v ge on,
etc.) �� / G� G Ui -C' �S f r/ / �Z-
1
ho
4 inn,
CESSPOOLS:
.4zd
Number and configuration: Depth-top of liquid to inlet invert:Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: r
Materials of construction:- Indication of groundwater: `
Inflow(cesspool must be pumped as part of inspection)
.j
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc
411
PRIVY:
Materials of construction: Dimensions:
Depth of Solids: k
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
d
etc.)
y
t
NI.�,Iii:�1.13.t
!y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM. INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
C—A/
O j J
DEPTH TO GROUNDWATER:
Depth to groundwater: 2 Z- Feet , ��
Meth o�f Aeterrtunation or Approximation: /� /29, 11,,a1V ZZ
(/ "i°I^/DID �c� Glib `l n
-7-