HomeMy WebLinkAbout0091 ROUTE 149 - Health 91 Route 149, Marstons Mills
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TOWN OF BARNSTABLE
.LOCATION � 1 �z t SEWAGE# Q®�C)
VILLAGE M al�, ASSESSOR'S MAP&PARCEL ��
'INSTALLER'S NAME&PHONE NO. 0 ��+�� Ova ti 4. Uo �fq
SEPTIC TANK CAPACITY n cL 1C
LEACHING FACILITY.(type) �ck 6c • Aze) G)d- ir+
NO.OF,BEDROOMS Q�V',au-e�- %A k® O QOX
OWNER
PERMIT DATE:'. 211 1 ,16,2() COMPLIANCE DATE: 31 Y 120
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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TOWN OF BARNSTABLE
LOCATION SEWAGE# ,)
VILLAGE M' JIWSESSOR'S MAP&PARCEL(3? ).- Or
INSTALLER'S NAME&PHONE NO. �C e ^t rw� r `
SEPTIC TANK CAPACITY C4 Sr
LEACHING FACILITY:(type) k 6r., \. •FAS Aze) xL o a. 1 4 S tt; k
NO.OF BEDROOMS � !� i 0
OWNER A e r 9".N&N
PERMIT DATE: f / ;� .) COMPLIANCE DATE: ,,.,1 •��
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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' Commonwealth of Massachusetts 0:-4- 008
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name v
required for
is Marstons Mills Ma 0264 3/2/2020
required for every
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 /'fyt9
filling out fors
on the computer, Sean M. Jones
use only the tab
key to move your Name of Inspector
cursor-do not S M Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com, SI4522
sean �onestitle5.com 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
3/2/2020
Inspectors 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.
Wnw.doc-rev.7126=8 Title 5 Offlelal Inspection Form Subsurface Sewage O(sposM System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information is required for every Marstons Mills Ma 02649 3/2/2020
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 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 91 Route 149 Marstons Mills is served by a Title V septic system consisting
of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. The system was
found to be in proper working condition at the time of inspection.
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):
l6inop.daa•rev.71!MiG Tills 5 Wdal lnapealiun Funri Subsurface,%wage 06puml 9yelmn•Paye 2 of la
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner owner's Name
information is Marstons Mills Ma 02649 3/2/2020
required for every -----.
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.)
2) System Conditionally Passes(cunt.):
❑ 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:
15ir V.Wc-nw.712S/2018 Title 5 Official Inspection forw Subsurface Searage Disposal System-Page 3 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
informarequired
is Marstons Mills Ma 02649 3/2/2020
required for every
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:
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
t5insp.doc-rev.U2812018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information is required for every Marstons Mills Ma 02649 3/2/2020
page Cdyfrown 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 %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 collform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 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
t6insp.doc.•rev,MUMS Title 5 Oftial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information is Marstons Mills Ma 02649 3/2/2020 _..
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection summary (cant.)
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 office of the Department.
6. You must indicate"yes"or"no"for each of the following for a/!inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
El ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation 310 CMR 15.302(5))
PP of distance is unacceptable)P
tBinsp.doc-rev.U26l2018 Tide 5 Of ciat inspection Form:Subsurface Sewage Dispoeai System-Page 6 of 10
` Commonwealth of Massachusetts
mamma Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owners Name
information is Marstons Mills Ma 02649 3/2/2020
required for every -
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 1
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
Description:
0
Number of current residents:
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 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date a unknown occupancy: Date
t5insp.doc•rev.7/A 018 Tpe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
600iiiiiia T Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information Is Marstons Mills Ma 02649 3/2/2020
required for every
page. Cityfrown 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: gate
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined? ._..,..._.�
Reason for um in :
P P 9
l5insp.doc-rev.7r2&2018 Title 5 Official inspection Form:Subsurface S"no Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram -
Owner owner's Name
information is Marstons Mills Ma 02649 3/2/2020
required for every Page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat.)
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:
original system installed 1988
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Joints in good condition no leakage, vented through roof.
t5insp.doc•rev.70=18 Title 5 Otrreial tnspection Form.Subsurraw Sewage Disposal System-Page 9 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information is Marstons Mills Ma 02649. 3/2/2020
.required for every
page Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1000 gallons
Dimensions: i
Sludge depth:
3"_
Distance from top of sludge to bottom of outlet tee or baffle 3.5'
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle 10" ----
How were dimensions determined? Opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet tank was not leaking and was structurally sound.
16insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sw"p Disposal System-Page 10 of 18
Commonwealth of Massachusetts
MMEM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information is Mars Mills Ma 02649 3/2/2020
required for®very page. Ciiyffown 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 [I fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
tsim pAoc•rev.7PA MI a Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 11 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram _.._-
Owner Owner's Name
information is Marstons Mills Ma 02649 3/2/2020
required for every
Page. City/Town State tip Code Date of Inspection
D. System Information (cont)
8. Tight or Holding Tank(cunt.)
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):
oilDepth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was replaced for inspection permit#2020-062 _...._.
t5insp.doc•rev.7126/2018 Title 5 Official tmpedion Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9.1 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information is Marstons Mills Ma 02649 3/2/2020
required for every
page. Citylrown State Zip Code Date of Inspection
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.):
•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: 1x1000
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
18ino Aw•rev.7t2WM18 Title 5 ONidal lnspedion pwm SuhsuHace Sewepe nlsrmsel System•Paoe 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner owner's Flame
Information is Marstons Mills Ma 02649 3/2/2020
required for every
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.):
s.a.s. consists of a 1000 gallon precast leach pit. Pit was video inspected and found dry with no signs
of past hydraulic overloading
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
p Y
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.7fY MIS Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149 �.
Property Address
Barbara Ingram
Owner Owner's Name
information is Marstons Mills Ma 02649 3/2/2020
required for every _ ..............�.__
required
City/Town State Zip Code Date of Inspedion
D. System Information (cone.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insi.doc•rev..7/26/201a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner owners Name
information is Marstons Mills Ma 02649 3/2/2020
required for every
- -- -
page, Cityffoym State Zip Code Date of Inspection
D. System Information {cone.}
14. Sketch 4f 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
VLK
2
a 16
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t5insp.doo•rev.7MCMI4 TIEte 5 Official ftped on Form Subsurfaw Sewage WOW System•PaW 16 of 18
I
4 Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owner's Name
information is Marstons Mills Ma 02649 3/2/2020
required for every page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
12'+
Estimated depth to high ground water. feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record .
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5h sp.doc•rev.7J26=8 We 5 Official Impaction Form:Subsurface Sewage Disposal System-Page 17 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Route 149
Property Address
Barbara Ingram
Owner Owners Name
information Is required for every Marstons Mills Ma 02649 3/2/2020
page. Cityfrown State Zip Code Date of inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Z 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
15insp.doc-rev.MUMS Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 15
NO. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rpplication for Misposaf 6pstem ConstrUttion Permit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No.q1 A %k(,5:i (j Get-S Qr,Mt wner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type o Buil mg:
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) gpd Design flow provided tj gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations Answer when applicable) J`L 14
LA 0 l � arc L
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 Health. l
i ed Date h�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. A Date Issued
r
No. Fee
V ' THE COMMONWEALTH OF MASSACHUSETTS Entered in c*Pu�
/PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Misposaf *pstem Construction Permit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System 6 4ividual Components
Location Address or Lot No.'it a{ \ G+ cAon M` wner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
QJ
Type o Bu'Sig:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures R
Design Flow(min.required) h/ gpd Design flow provided gpd
Plan Date Number of sheets Revision Daie
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ;-
Date last inspected: m
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 iri'opgration until a Certificate of
Compliance has been issued by this Board of Health.
/7 a Pate
Application Approved by /. J L Daie
Application Disapproved by Date
for the following reasons
Permit No. ''y Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
11 THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
CPrtIfILatE Df CDIYCpYIaICLE
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired V) Upgraded
( )
Abandoned( )by
at Cle� ��, '�`; �( C has been constructed in accord. c
with the provisions of Title 5 and the for Disposal System Construction Permit No 2 z )
r
Installer S_ kA �, ,�(A' Designer
#bedrooms v /a Approved design flow A) Q gpd
The issuance of this' /permit shall not be construed as a guarantee that the system will on designed.
Date y / d Inspector C4
-------------=-----------------------7---------------------------------------------------------------------------------------------
No. AM/0 —
FeeTHE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pBtrm Construction Vermit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at e} ( ? M .C lr!,
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:Constructi n my§t be completed within three years of the date of this permit.
Date Approved by
Engineering Dept. (3rd floor) Map Parcel C Permit# 3( 2i c4
C
House# Ot ` Date Issued 2"j
✓Board of Health(3rd floor)(8:15 -9:30/1:00- . � ;�j/ - �� 0
/Conservation Office (4th floor)(8:30-9:30/1:00-2:00 p V d
glannifig-DePt.(1st floor/School Admin. Bldg.) INN
DeAnUiuc-Elan Approved by Planning Board 19 r;- A SYST '
INSTALLED IN
C
TOWN OF BARNSTABLFWITH T1 L 039.
ui TOWS lding Permit ApplicatiAPVIRONME DL T1D �®
Project Street Address
Village A
Owner =-'a"'ravvv Address q�, w,
Telephones . S f hk. OM0
Permit Request
t q
�
First Floor , square feet Second Floor - �sC care feet
q
Construction Type �
Estimated Project Cost $ _�� '0� , pd
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes t No On Old King's Highway ❑Yes 'ANo
Basement Type: ❑Full Crawl „Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) .
Number of Baths: Full:. Existing�_ New Half: Existing New
No.of Bedrooms: Existing New �L —
Total Room Count(not including baths): Existing New �' First Floor Room Count
Heat Type and Fuel: „Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes PNo Fireplaces: Existing .A- New Existing wood/coal stove ❑Yes �No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
Attached(size) �" ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes *0 If yes, site plan review#
Current Use Proposed Use
Builder Information
Name �str Telephone Number_ d - -
Address `-� /v��� . �Y�T License#
3 Home Improvement Contractor#
orker's Compensation# ,b Y V�/�2bISCA
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCyl\DEB ESULTING FROM THIS PROJECT WILL BE TAKEN TO � ����►U��1 --
SIGNATURE DATE
BUILDING PER T DE IED FOR THE F WING RE SON S)
Engineering Dept. (3rd floor) Map Parcel Permit#_- at 21 V
House# q k I Date Issued
Z_ p
✓Board of Health(3rd floor)(8:15 -9:30/1:00- ?L°�h� na y �S- D 0
//Conservation Office (4th floor)(8:30- 9:30/1:00-2:00)
Fog-Dept.(1st floor/School Admin. Bldg.) �IHE
De4PAUuaTJan Approved by Planning Board 19 SE a',i 3YCos-7'�
INSTALLED I ! �79
TOWN OF BARNSTABLFWITH TITL
°
uilding Permit ApplicatiOVIRDNMENTAL CC AN®
TBWN REClJLI��'�'lC4�S
Project Street Address
Village 1
Owner . Address MA In.
Telephones - �� �S o Mi 0�Tb
Permit Request .
" q
q ` `^ 1
First Floor Si , square feet Second Floor - square feet
Construction Type
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes t$.No On Old King's Highway ❑Yes 'ANo
Basement Type: ❑Full Crawl C$L%Ikout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) .
Number of Baths: Full: Existing New Half: Existing New
No. of Bedrooms: Existing New
Total Room Count(not including baths): Existing 2> New �' First Floor Room Count '
Heat Type and Fuel: �LGas ❑Oil ❑Electric ❑Other
Central Air ❑Yes PNo Fireplaces: Existing A— New Existing wood/coal stove ❑Yes "KNo
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
Attached(size) �p� 5�_ ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes *0 If yes, site plan review#
Current Use Proposed Use
` Buflder Information
Name 3 �s Telephone NumberVQ�
Address `-� ��T License#L S OG 41
3 Home Improvement Contractor#
orker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTI N DEB ESULTING FROM THIS PROJECT WILL BE TAKEN TOta-
SIGNATURE DATE
BUILDING PER T DE IED FOR THE FO WING RE SON(S)
,2
�\ COMMONWEALTH OF WSSAC9V SETTS��,` Ift
EXECUTIVE OFFICE OF ENVIRONMEN A�F�IRS
��// { j
DEPARTMENT OF EN-VIRONNIE\TAL�`PROTe(CTT
ONE WINTER STREET. BOSTON. NIA 02106 b1'� ' 'St�(.Tk'0" �99
Fq�rBggNsr
r: nFpTAe�F �
WTLLIA"F WELD fG; ! �.�^ TRLDI C0)E
Gov erne
ARGEO PAUL CELLVCCi DAVID B STRL+E
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions
PART A
ROV f e- ( CERTIFICATION
Property Address: 91 ���vT f t +h tas.-K-6Ns tA%As Address of Owner: fitS Tpc�eftw%
Date of Inspection: Idlujlet-) Of different) - o16 W�jGV�, LO
Name of Inspector: H,a et o � I l�E�ecem t4"lW ,M.1\% ( Kp, s
I am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:� a,r4-,'e En rr I'r�K P.�'st- � ~
Mailing Address: Pen Acpx e_3?s'�j H A9&e-eg- H -#9- c;' P—C(-q
Telephone Number: r5e42
CERTIFICATION STATEMENT
I cenif that I have personall,, inspected the selvage disposa! system a: this address and that the information reported beloK is true. accurate
and complete as o;the time of inspecoo The inspection %as performed based on my training and experience in the proper iuncion and
rramtenartce of on-site selvage d,sposa s\'stems The syste-n
Passes
_ Ccnc-t,o^a:;,, Passes
♦ee--, Furhe• Eva'uat:on 9\ the Local .Approving Autnonr�
Fa.•s
Inspector's Signature: UIL Date:
The S,,s:e^ Insoeco• sha" submit a cop,, of this inspecoon reocr, to the Approving Authority within thirty (30i days of completing this
tnspec.or. It the s,,stem is a shared system o• has a design flolv of 10,000 gad or greater, the inspector and the system owner va!I submit
the repo,: to the aaoropriate repor:ai office of the Department of Environmental Protection. The orig:nal should be sent to the system owner
and copes sent to the buve•..if applicable, and the approving authorin
INSPECTION SUMMARY: Check A, B, C, or D.
Al SYSTEM PASSES:
_ I have not fouad.any information which indicates that the system violates any of the failure critgria as defined in 310 Cti12 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS.
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upon
of the replacement or repair, as roved b the Board of Health, will s.
completionp p aPP y P�
Indicate yes, no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Cornpliance lanached; indicating that the tank was installed within twenty (20)1 years prior to the date of the inspection; or
the septic tank, whether or not meta!, is cracker, structurally unsound, shows subs:artial infiltranon or exfiltrxion, or tank
failure is imminent The system will pass inspection if the existing septic tank is replaced with a contorrning septic tank
as approved by the Board of Health.
Irol':/od 04 ':5 '9'1 DAp• 1 of 1C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
61 SYSTEM CONDITIONALLY PASSES iconuni-d
_ Sewage backup or breakout or high static water level observed in the distribution b x is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will s inspection if(with approva' of the
Board of Health;. Describe observations-
broken pipe(s) are replaced ,
obstruction is removed
distribution box is levelled or replaced.
The system required pumping more than four times a year due to br or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_•c_` broken pipes; are replaces
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD Of HEALTH:
Conditions exist which require furthe, evaluation by the Board Health in order to determine if the system is falling to protect the
public health, sairy and the environment
1) SYSTEM WILL PASS UNLESS BOARD OF HE,ILTH DETER• INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or pri+-, is within 50 iee: of a surfa7 water
Cesspoo' or pri+) is +ithin 50 fee: of a bon Ong vegetated wetland or a salt marsh.
2) SYSTEM Vi'lll FAIL UNLESS THE BOARD OF H lTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNE THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The s+'s;err has a septic tank and oil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water sup y.
Tne system has a septic cant rid soil absorption system and the SAS is within a Zone I of a public water sup,-,Iv well.
The system has a septic tan and soil absorption system and the SAS is within SO feet of a private water supply well.
The system has a septic to and soil absorption system and the SAS is less than 100 feet but 50 feet or more frcm a
private water supply we , uniess a we!I waver analysis for coliform bacteria and volatile organic compounds ind,cates that
the well is free from p lution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. M hod used to determine distance (approximation not valid)..
3) OTHER
St:BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM
PART A -
CERTIFICATIO% (continued)
Propert% Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either "Yes' or 'No' as to each of the following
I have determined that the system violates one or more of the following failure cr erra as defined in 310 CMR 15.303 The oas•*
for this determination is identified below. The Board of Health should be con ed to determine what will be necessary to torte^
the failure
Yes No
Backyp of sewage into facility or system component due to an o erloaded or clogged SAS or cesspool.
_ Discharge or pondrng of effluent to the surface of the ground r surface waters due to an overloaded or clogged SAS or
_. cesspool.
Stain houid level in the dis:rrb anon box above outlet in n due to an overloaded or clogged SAS or cesspoo!
Licurd depth rr cesspoo! is less than 6- below invert available volume is iess than 1/2 day tlov.
Recu-red pumping more thar, 4 times in the last ye r NOT due to clogged or obstruaeo pipe s
Numoer o'times pumped_.
An% portion o;the Soi: Aosorptron S,.•stem. ce pool or privy is below the high grouncivve• eievarro-.
A^%, por::or, o*.a cesspool or privy is w rthrr. 00 feet of a surface water supply or tributar to a surface Ovate• supplN
And po':ion o:a cesspoo' Or prrv% is w rth r a Zone I of a public well.
Any o:a cesspoo' o• pr;a- hin 50 fee: of a private water supph well
Any poi-or o:a cesspoo' or prr%1• is ess than 100 fee: but greater than 50 fee: from a private water supoh• well with no
acceptable Ovate• qualm anahs-s the well has been analyzed to be acceptable. anach coo• of well water analvsrs for
colrform bac ,ia vo!xde organic co-pounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
tou must indicate e;:he• "Yes' or "%o" as to a ch of the following.
The fo!;ow;ng vite•,a aor;% to !arg.0
systems in addrron to the criteria above.
The system serves a facrlm with design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safer? and th environment because one or more of the following conditions exist
Yes No
the system is wi in 400 feet of a surface drinking water supply
the system is ithin 200 feet of a tributary to a surface drinking water supply
the system s located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone 11 of a
public w er supply well)
The owner or operator of ny such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 U1 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
Propert% Address: 9S co6:iic—x ,
Owner: U_niWn
Date of Inspection: Iohkctl
�
' ..
Check if the following have been done. You must indicate either"Yes"or 'No"as to each of the following:
Yes N. o
_ Pumping information was provided by the owner,occupant, or Board of Health.
TT hone of the system components have been pumped for at least two weeks and the system has been receiving normal
1�.
flow races during that period. Large volumes of water have not been introduced into the system recer,tl' or
as part of this inspection
As bull: plans have bee oxa:ned and examined. Note if they are not available with WA
The fac:ld� or 6%eking %%a5 inspected for signs o' sewage back-up
_ The systern does not receive non-sanitary or industrial waste flow.
_ The site %%as inspected for signs 9f breakou:
X _ All s%me-r co^+poner-ai. excluding the So-1 Aosorpaon System, have been located on the site. Y
X•, _ The se;:,c tai� man+ o;es Aere uncovered. opened. and the interior of the septic tank was inspected for condaio-. of
baffies or tees. materia� o-cor�structiori. dimensions, deptn of liquid,depth of sludge. depth of scum.
The size and loca:iol, o'the So,' Absorption System on the site has been determined based on
Tne iac•ia, om ne• ,ane occupants. if dirterent trorr. ov,-neri were provided with rniormation on the proper maintenance o-
Sub-Surface Disposal Svs;ern.
Ex,s;irg mix-ration Ex P;an a: B O H
_ De:errn!ned ir: the meld r any of the failure criteria related to Part C is at issue, approximation+ of distance is
unaccevaDie 11; 302 3•b'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..m
PART C
SYSTEM INFORMATION
Propert% Address:
Owner:*FVjt*M
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL: '
Design flo% 35e p.cllbedroo_rr. for S.A�S
Number of bedrooms o2_
Number o-'current residents,Q
Garbage g-, der (yes or no-
Laundry co-•^ected to system (yes or no'�J
Seasonal use Ives or no,. IJ
VVater meter readings• if available (last two i2 year usage tgpd): 1J
Sump Pump (ves or not s-)
Las: dare o`occupancy UPC.
COn1MERC14L'INDUSTRIAL:
Type of establishmen:
Design fio%% _Ea!ionsda%
Grease trap present Ives or no_
Indus:na! 1'laste Holdmg Tani; presen;. ves or no
Non-sanitan v,aste d-scnargec to the Tr•,ie 5 ssem ;ves or no_
\%ater meter read,ng; if a,ailabie
Las:pate of o c.;z-.c.
OTHER: Describe
Last oate o1 occuz�anc.
GENERAL INFORMATION
PUMPING RECORDS and source of i fprma:to,
II�1-
System pumped as par; of inspection: tees or no.__t,.)d
If yes, volume pumped ¢alions _
Reason for pumping
TYPE OF SYSTEM
Septic tank'd*st rbarre+--- 'soil absorption system
Singie cesspool
Overflow cesspool
Pm)-
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site. (yes or no) Mo
(revised 04/25/9'i Page 5 of 10
SUBSURFACE SB%AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �( GT)11
Owner. a
Date of nspbction:
6
BUILDING SEWER:
(Locate on site plant NO
Depth below grade.
Material of construct ton: _cast iron _40 P`dC _other texplain`
Distance from private water supply well or suction I1
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan
Depth belo% grade
K
Materia' of construction: _,concrete _meta _Fiberglass _Polyethylene _othenexpla n
If tank is metal. Its: age _ 1• age cor.iamec b\ Cen;ficxe of Compuartce _(tes,Ao
Dimensions IQOU�,M'�
Sludge depth
Distance from top o: sludge to bortorn of out;e: tee o• ba-;;e
Scum thickness 0 _ t(
Distance from top of scum to top v outlet tee or ba"ie J*Z tf
Distance from bottom of scorn to bocoT of outlet tee c' bake ly_
Now dimensions were determined
Comments.
trecommendation for pumping rondrtion of irnet anc outlet tees or baffles, depth of liquid level in relation to outlet invert, trurural
integrm, evidence of leakage. etc.(
LD
GREASE TRAP:
(locate on site plan:
Depth below grade.
Material of construction: _concrete _metal Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle.
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping.
Comments:
(recommendation for pumping, condition of i,,let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.,-
(rev-.sod 04125.17) Page 6 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM I%SPECTIO% FORM
='PART C
:�jSYSTEM INFORMATION 1continued)
Propert. Address:
O'A ner:
Date of Inspection:
TIGHT OR HOLDI%G TANK: "'Tank must.-be pumped prior to,or at time, of inspection:
(locate on site plan,
Depth below grade _
Material of construction _concrete _metal _Fiberglass _Polyethylene _other(ezplain)
Dimensions.
Capacity gallons
Desig^ floM ga:io^sda.
.arm leve' A:a•rn in %%ork:ng order _ Yes. _ No
Da!e of previous pump.ng
Comments
(condition of role: tee cond-::or o* a'a,rr and float switches. etc.t
DISTRIBUTICI% BOX.
oocxe on sl:e p a-.
Dec:'' v i:cL-d lee ace•.e c.a;e: m�e^
Com-ne-ts
tno:e :� level a-d da":G.: Or :s ecua evidence of sores carn•o.•er e��dence of leakage into or out of box, etc.t
I
I
PUMP CHkMBER
(locate on site plan
Pumps :n working order. (Yes or No,
A:arms in working order (l es or No
Comments. /psand
(note condition of pump chamber, condition of ppurtenances, etc.)
':'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
u►ICi1
SOIL ABSORPTION SYSTEM (SAS):45
(locate on site.plan, if possible, exca,.ation not required, but may be approximated by non-intrusive methods,
If not determined to be present, explain:
Type
leaching pits. numbor.__mL
leaching chambers, number._
leaching galleries, number.
leaching trenches. numbe"length
leaching fieids, numbe,, d,-+ensio^s
ove ,ow cesspool, number
Alternanve wstem
Name of Tecnnoiog\
Comments
en
inoote condition o'so,i. s+g^s o!hydraulic failuie, leve° of ponding§ondition of vegetation, etc.'
nn v
��11
CESSPOOLS:
(locate on site p:a"
Nurnbe, and cc-:,g.:.a.,c_
Depth-top of licjid to iniet inter.
Depth of solids lave-
Depth of scum lave
Dimensions of cesspoo:
Materials of constructio,
Indication of g•oundNate-
inflo- tcesspool must oe pumpeC as par, of inspection
Comments.
(note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions.
Depth of solids. _
Comments
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORM
PART C
SYSTEM I%FORMATION''(continuedi
Properv, Address: 01
Owner: ),r.XJ44vA
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 (locate where public water supply comes into house)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM
PART C
"SYSTEM INFORMATION (continued)
Propert% Address9t wbiTow,
Owner:T QN
Date of Inspection:'6 a
1
Depth to GroundAate• D Fee;
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation o�Site (Aounmg property, observation hole, basemen: sump etc.)
Determine it from local conditions
Cneck Iota Ecarc o• nea':r
Chec� FEMA macs
Cneck pumpinF reco,ds
Cnec►. Ioca' eua:a:o- irs:a'le•s
use LSCE Da--a
r
Desc•!be in %3.:' 0•% %c- esa='!s6%er. the '�,E`' Ground"a'.e' Elevation. (Must be completed
U� C-
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TOW14 OF BARNS'rABLE
LOCATION_ �� Sl, ±4%1�( � � _. SEWAGi?
VILLAGE— �',�j // . ASSESSOR'S MAP & TOT
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II+iST'ALLEIt'S NABrIE & PHONE Nt), I I I.- i a _ LM
SEPTIC TANK CAil'ACITY �,2.
LEACHING FACILITYAtype)LP
►O. OIL BEDROOMS PRIVATE WELL OR PUI31.,I.0 WATER__
BUILDER OR OWNER
DATE PERMIT ISSUED: _ --
DATE COMPLIANCI;
VARIANCE CR kN1'.F,D: Yes__._ ----No�/
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No---f.1. . -- .. Fxs...... .... .............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH „
.........Town- ---- -------------OF.......Barnstable
.................................---......-........................................
Appliration for DhiposFal Works (Limtrurtion Vrrtnit
Application is hereby made for a Permit to Construct ( ) or Repair VX) an Individual Sewage Disposal
System at:
91 Rt. 149 Marstons Mills
................_................................................................................ ----.........----------------..................---•-----......------------------•-----------------
Location-Address or Lot No.
Pr.1S�1 2-q q.in's....................................••--------
Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
aDwelling-X-ANo. of Bedrooms............ ..............................Expansion Attic ( ) Garbage Grinder ( )
a4 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................
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 ( )
Percolation Test Results Performed by.......................................................................... Date.......................................
aTest Pit No. 1----------------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.........................................................................................................................--------------------.........................
S.and......................................................................----------........-•-----•-•--••--••....--V
W
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable----------1,-I_Q.Q_0___-ga_1.1.97n....tank...................................
-------------------------------------------------------------------------------------------------------------------1.-1QQ Q- a1,lan p 1-t---------------------......--•--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
TT�-IF^
the provisions of 4 :: of the State Sanitary Code—Th undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee,4 issued oard of h.
Signe •. •-•-•-• ° ra----------------_- •....
Date
ApplicationApproved By.... ••••• . ....... .... .. .... ....... ---------------------------------------
Date
Application Disapproved for the following reasons:_.. ........................
----------•---------••................................••_.._ ----------.._
---------------------•------------------...---------------------••---------------•---------•-------....--••--•••-•-•••••-•-•••-••--••---•-•---•-••------------••--••••-•-•-•-•-•----••-•-•-•••-•........
^ �!%pe Date
Permit No.---(�?--°- - ----•�{--._. --------•-------- Issued...............•-----------------------•-----
- L�tL
A.
i
Q c:_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- ------------_..-.OF.......Barn.s.trab-le--------------------.___-----------,__._-----------
Appliration for Disposal Works Tonstrnrtion pumit
Application is hereby made for a Permit to Construct ( ) or Repair, an Individual Sewage Disposal
System at:
taxoars...MILLS----.....-•----•--------- -----••------•----....._..........----._....---..........-----------........_..-------•----------.
Location_Address or Lot No.
t.g3 f'1'c2 -------•------------------------------------- ..........-•....................................................................................
P C2'a;
wner Address
►Wa
J";-F:14-3-ztUF?Jc'i""'" Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........... _..............................Expansion Attic ( ) Garbage Grinder ( )
'4 Other— e of Building __.________ No. of ersons____________________________ Showers
tlt iYP g ----------------- P ( ) — Cafeteria ( )
04 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.
3 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........................
PL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-__-_________________-
a •--•-•••••--•--•-----•••-••-••-------•-•--------••-••-••-----•----•••----------•••-----•---------••--.....---•-•-•................•--•••- ---------------
0 Description of Soil..................................................................................................---------------------------------------------•--
v ------------•----------Sand---------------•--••--------------_______--------------------------•----------------------------------••-----------
W
M. ------------------------- -------•-....•--•-----••----••--•---••---•---•-•--------•----••••-•••-•-----•---••---•--------••••••--••-•-•--------•--•-•-•-•--••-••••••••••--•--•------•••------•----------
U Nature of Repairs or Alterations—Answer when applicable__...____1__I_W10---��a_1 t.. _z� ___________________________________
••••-----••---••---••••-----•-----•--•-•••••••-•-----••--------•--•----••-•-••------•--•-•----•--•---------•--•---1__I U-0 Callan t
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of t't iT rl•^
� .:.;. 5 of the State Sanitary Code—Th undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beepr issued he oar d of ea th.
. s
Signed---.. ._..--_•-- =---...---. �-•--------••--•-•--- ------g-/--2-:"s,�=Aa--•---
�j Date
Application Approved By.... ........._ - °
'--------•- •••-�� •--r'•--•------- ........................................
Date
Application Disapproved for the following reasons:•-- •-------••--••-••••••-•---•----•---------------•-•••••---•---•••--••-•-------•-•-.......................
------------------------------------------------------------------------------- Dau
PermitNo.•••CL. J................. Issued.......................................................
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........T17�;n................OF..............Barnstable
..............................................................
�nrtif iratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired t.XJX
by......................... ------•--•-------------•-•---•----------•-------....--------.......-------.....---.......----------.....---•-•-----------------------••--
Installer
at__.._..--•------•-•---••-91••Rte•.--- 149---Mars4 o.ns---i i11s--------------------••--••----------------------------•----•------------
has been installed in accordance with the provisions of TIr" _ e Sanitary (' a r-r e in the
application for Disposal Works Construction Permit No.__. �`� _ dated......... ...... ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.........' O.W.n....................0F........_...B rnstZble
NO. :............. FEE.... ;®®
Disposal Works Tontrurtion famit
Permission is hereby granted.................. -.-pia ' I)n-r...........................................................................................
to Construct ( ) or Repair XX)X an Individual Sewage Disposal System
at N91........01-...Rt-e. -4-4$--XaX_St 3n_S...Ii LLS._.....--.-------•-------------------•-•-------- » ------- ---_______________
Street ti r 7
as shown on the application for Disposal Works Construction Pern_�F"
r� �ated_�___J/.by
...........
.
IA 1E " He
DATE-------`---- -- •-------------•-----•--...,.................. Boar o
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS