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HomeMy WebLinkAbout0300 ROUTE 149 - Health AI 9 i s. 1. ................... 9.0 THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALT _... .. . . . ..._.OF........ ... ..� ti.... .. ' Appliration -for Big nittl Works C omitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem at: D b �,..Ocat ddrs � . .............................___.......-- -•-------- - ----------------•--•------ •... r Address e e.................... .............In-stall-r-------•---•--•--•--•-••-•---------•- Address Type of Building Size Lot__,l• U `welling—No. of Bedrooms-------------------------------------------Expansion Attic (V1 Garbage Grinder ( ) per, Other—Type of Building ------- ----------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------ W Design Flow.....:3a............................gallons per person per day. Total daily flow------------------------------------------..gallons. 9 Septic Tank—Liquid capacity./q. gallons Length................ Width.--___-._..--- Diameter_-..__..-..-_-_ Depth._._._-__...._ 3 Dispossal Trench—No--------------------- Width.................... Total Length___--.__---_____--_ Total leaching area..__•---------------sq. ft. Seepage Pit No-------1---------- Diameter..l4.°_9.*)e th below inl t..... ............ T leachi Z Other Distribution box ( ) Dosing tank ( ) �— �G,* - /X-M kw ' a Percolation Test Results Performed by-------- --------:........................................................ Date----------------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._-------_----.__..__-- r14 Test Pit No. 2................minutes per inch Depth of Test Pit-_-______--_--_-_- Depth to gr and water--_------------------- P4 ------- ----------- ----------- --------- 0 "Description of Soil---------------- s _.... -- __. _ ---• ---_-- ._------------- ----- V - — - ------ --� 41 ------------- x ------------------------------------- --------------------------------------- --------------------------------------------------------------------------------------------------------------4 -- --------- V Nature of Repairs Alter `bons—Answer whe, app•cable, ------- - --- ------------------- ------------------------ Agreement: f t di 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 r er agrees not to place system in operation until a Certificate of Compliance has ee is ed by the bo of eal ned.--- . • ••---....... Application Approved B ----....... -•----.•... -•-• Da fF 7 Z/ PP PP y - — �� ` Date I Application Disapproved for the following reasons:: ----------------------------------------- Date Permit No...................... Issued... Date Fus.. ..D...No. ---•-- r THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL,T .... . ... .. Appliration -fox Dbi' ial Workii Towitrurtiott Vrrmft ? Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal f System at: , ff / 7......� ...........�S�!r 3 ---------------------------------------------------- t ,5ddr ss or t N0# ----------- -------- ----- - -- -- ------------- ...•. ne ✓/�l C Address q Installer. Address Q Type of Building Size Lot--._ Geh�s Sep-�faeC welling—No. of Bedrooms............................................Expansion Attic (t/'f ' Garbage Grinder ( ) p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q, Other fixtures ..........................................'- W Design Flow----_'----------------------------gallons per person per day. Total daily flow__-_-----_-�--_--_aQ____-__-__.-.--.--..gallons. 9 Septic Tank—Liquid capacity APOgallons Length---------------- Width................ Diameter--------.------- Depth._.----__.----- Disposal Trench—N . ................... Width.................... Total Length-------------------- Total leaching a rea....................sq. ft. Seepage Pit No------- Diameter..,lp!v!R. .�rDepth below inl t..... ............ T a leachil�a „________Sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `.-' PA AN v6, Percolation Test Results Performed by.......................................................................... Date------------------------------------ . a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.._-..----_----_-... (i, Test Pit No. 2................minutes per inch Dept of Test Pit-------------------- Depth to gr and water------------------------ ------ /' �------------ ---- - ••- Description of Soil ice. '� - ----- --- ------- ------ LLB // /� .. U .................................. .. �------ •----(--- ---_........_ _.•--•--'-'mTt^---...-'-•-- -___.""___~-___..__..___.----.._...___._ .._ _..a------. M - !------------------------------'--.-..-....---------------------------------_--_--_---------------•----------_------•--------•----------------------•----------------------•---•-------•/---------------- hi, li Nature of Repairs or Alterations—Answer when applicable..............:................................................................................. ----------------------------------------------------------- ......................-..=................ ---------.------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with- the provisio� of Article XI of the.State Sanitary Code—The undersigned rt er agrees not to place t system in operation uiftil a Certificate of Compliance has ee is ed by the bo d of ealth. ned.... ---- --- --------- --- =`� M / �f t. Da 7 Application Approved By........:... ... .......•-- .............••--C't.. .= - � / Date `.. Application Disapproved for the following reasons:................................................... ........................................................- Ay Date PermitNo......................................................... Issued......................................................... r Date ti THE COMMONWEALTH MASSACHUSETTS �: . BOARD O E LTH ..., - OR.:....6 * .......... . T I 'IS TO CERTIF hat t ndividual Sewage Disposal System constructed ( ) or Repaired ) by...... -- -• -•------ .... •. • _. .- -- -------------------------- ------------- I taller at.., •-• . . ,..� l.'��_......... --•- - --G+l r.�l s... . , has been in led,.in accordance with the provisions of Article XI �jf T e tate Sanitary Code As described in the ;- application for Disposal Works.Construction Permit No.--___-____--- s .._.. dated.._. `.7_.'�d.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.. . DATE..............................---------------------------------------------•-- Inspector------------------ ••---•--------- ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEAL'T rFZit00 / . . o1. .. ......O F....... •--- 0......................... ;_U- 16-10 FEE-- -- • .......... j Permission i reby granted ------ - ---• ---- •. ........................1.4041 •----•--- ' to Constr ct ((/) or Repat ( ) ndi id . Sewage sp tem" ` at No= =-1f--'• �} ....... _.,.- ---C-----------44al,-4 ----- -, -•-r---- r 'F j : ? Street f as shown on t�Hea�nplicat>on for Dis 'osal Works Construction Pe No. .__. _ .... ed____ ___.7.__._...._........ . P ,. . L�C�Lt. DATE........... If Board of Health f FORM 1255 HOBBS & WARREN'. INC.. PUBLISHERS - - y .7 -913= ell t1J a ' CO 0z00,00 {. 61 ✓ 10 17 4 May ,13. 2019 14:01 HP Fax page 1 b�OqD Commonwealth of Massachusetts I Title 5 Official Inspection Form '"' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt.149 �. Property Address X1. Sherin &Dean Clark Owner Owner's Name C" information is Marstons Mills MA 02648 t�5-2-19 required for every t page, City/Town 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. �tN of Important:When A. Inspector filling out forms Information on the computer, `mod JAMES Gi, . use only the tab James D.Sears 0' n r n n n key to move your Name of Inspector y I'Q < cursor-do not Ca ewide Enterprises �' CIA- use .k P P . , the returnt-'<.` key. Company Name 153 Commercial Street % rr5lnu _Q Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ua��—191" 5-3-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 16insp.doc•rev.7/26/2018 Title 9 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 16 C May ,13 2019 14:01 HP Fax page 2 ��° N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt,149 Property Address Sherin &Dean Clark Owner Owner's Name information is every Marstons Mills required for eve MA 02648 5-2-19 page, Cih'lTown 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 I&304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal Tank and two pits Note: Pits piped in line 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.712612018 Title 5 omclal Impaction Form:Subsurface Sewage Disposal System-Page 2 of 1a May ,13 2019 14:01 HP Fax page 3 Commonwealth of Massachusetts r - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Rt.149 Property Address Sherin &Dean Clark Owner Owners Name information is required for every Marstons Mills MA 02648 5-2-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cant.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms 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: islnsp.doc•rev.7l2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 3 of 18 IV I __ May ,13 2019 14:01 HP Fax page 4 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt.149 Property Address Sherin &Dean Clark Owner Owner's Name information is Marstons Millsrequired for every MA 02648 5-2-19 page. CitY1 Dwn 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.712612018 Title 6 Official Inspection Fort:Subsurface Sewage Disposal System-Page 4 of 18 May .13 2019 14:01 HP Fax page 5 :C�, commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o< 300 Rt.149 Property Address Sherin &Dean Clark Owner Owners Name information is every Marstons Mills required for eve MA 02648 5-2-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No A/A ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6"below invert or available volume is less than Yz day flow jP11-s ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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 11 of a public water supply well t5lnsp.doc-ray.712812018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 5 cr 18 May 13 2019 14:01 HP Fax page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt.149 Property Address Sherin &Dean Clark Owner Owner's Name information is required for every Marstons Mills MA 02648 5-2-19 page. City/TDwn State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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 ofthe system obtained and examined?(If they,were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 15insp.doc-rev.7f26IM18 Title 5 Official Inspectlon Form:Subsurface sewage Disposal System-Page 6 of 18 f May •13 2019 14:01 HP Fax page 7 �t\ Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 300 Rt.149 Property Address Sherin &Dean Clark Owner Owner's Name information is �' Marstons Mills required for every MA 02648 5-2-19 page_ City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 4 DESIGN Flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: 1000 Gal.Tank and Two Pit's. Number of current residents: 0 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2017-17,000Gals Detail; 2018-24,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5hsp4oc•rev.7/26/2019 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 7 or i8 i May .13 2019 14:01 HP Fax page 8 t. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt.149 Property Address Sherin 81 Dean Clark Owner Owner's Name information is required for every Marstons Mills MA 02W 5-2-19 page. City/Tom State ZIP Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.Coc•rev.71261201s Title 5 Official Inspection Form:Subsurface Sewage 17lsposal System•Page s of is May,13 2019 14:01 HP Fax page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt.149 Property Address Sherin & Dean Clark Owner Owners Name information is required for every Marstons Mills MA 02648 5-2-19 page. City[rown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,dWWM00WbW 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 34"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.): Pipeing is 4" PVC SCH-40. t5insp.doc-rev.712&2018 Title 5 Ofklal inspection Form:Subsurface Sewage Disposal System-Page 9 or 18 May.13 2019 14:01 HP Fax page 10 Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments v 300 Rt.149 Property Address Sherin &Dean Clark Owner Owner's Name Inforrequired is every Marstons MITI$ re wired for eve MA 02648 5-2-19 page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 2'feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12' Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank at 2' below grade wlboth covers at 9", In and outlet baffle's. No sign of leakage or over loading. t5insp.doc-rev.W26M18 Title 5 Cf6cial Inspection Form:Subsurface Sewage Oieposel System•Page 10 of 18 May .13 2019 14:02 HP Fax page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,. 300 Rt.149 Property Address Sherin 8r Dean Clark Owner Owner's Name information Is every Marstons Mills required for eve MA 02648 5-2-19 page. dit Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7126f2018 Title 5 Official Inspeckn Form:Subsurface Sewage Disposal System-Page 11 of 18 May.13 2019 14:02 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt,149 Property Address Sherin &Dean Clark Owner Owner's Name information is every Marstons Mills required for eve MA 02648 5-2-19 page. City[Town State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dace Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Box 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.): t5inspAoc•rev.W28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 May. 13 2019 14:02 HP Fax page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments h 300 Rt.149 Property Address Sherin & Dean Clark Owner Owners Name information is required for every Marstons Mills MA 02648 5-2-19 page. Clty[Town State Zip Code Date of Inspection D. System information (cont.) 10. Pump Chamber(locate cn 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: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: is nsp.doc•rev.726/2018 Title 5 Official Inspecdon Form;Subsurface Sewage Disposal S tern•Pa ge age 13 of 18 l May.13 2019 14:02 HID Fax page 14 Commonwealth of Massachusetts �- I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt,149 Property address Sherin &Dean Clark Owner Owner's Name information is every Marstons Mills required for eve MA 02648 5-2-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is two 100 Gal. Precast Pits Piped In line. Pit#1 at 30" below grade w/cover at 15",6" water w/outlet tee. Pit#2 at 50"below grade w/cover at 28" dry. Pit is clean like new. 12. Cesspools p (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): lbinap.doc•rev.7rA12018 Title 5 Official Inspadon Form:Subsurface Sewage Disposal System•Pags 14 of 18 May, 13 201.9 14:02 HP Fax page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Rt.149 Property Address Sherin &Dean Clark Owner Owner's Name information is required for every Marstons Mills MA 02648 5-2-19 page. Cityrro" State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials cf construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.dx•rev.7/26/2018 Title 5 O1lictal Inspection Form:Subsurface Sewage Cisposal System•Page 15 of 18 5 May. 13 2019 14:02 HP Fax page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments vt��)V 300 Rt.149 Property Address Sherin &Dean Clark ki Owner Owner's Name information is required for every Marstons Mills MA 02648 5-2-19 page. City]7own State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ,/ : 18, R-I = is 4- 3= 31 c-y. �Lf-,3" D oy 8 R EAR c Dice l o 9 �► O 3 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Ofltdal Inspecton Form:SubsuRace Sewage Dis sal System•P g pa yst age 16 or 18 r May, 13 2019 14:02 HP Fax page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Rt.149 Property Address Sherin&Dean Clark Owner Owner's Name information is required for every Marstons Mills MA 02648 5-2-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to 12.5' p �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 US GS database- explain- You must describe how you established the high groundwater elevation: 12'.5"G.W.. Bottom of Pit at 10'below grade, Bottom of pit at 2 5' above G W Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form Subsurface Sewage Oisposal system-page 17 of 18 - - I I May, 1:3 2019 14:02 HP Fax page 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments r 300 Rt.149 Property Address Sherin &Dean Clark Owner Owner's Name information is required for every Marstons Mills MA 02648 5-2-19 page, City/Town siate Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1,2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included f� 0 0� a s• Gw t5insp.doc•rev.7/26/2018 Tide 5 Official inspection Form:Subsurface Sewage Disposal System•page 18 of le COMMONWt-,ALT'H"OF'MASSACHUSETTS EXECUTIVE`OFFICE;'OF ENVIRONMENTAL AFFAIRS ; DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ,� /�/f /�ur��i•,t/Yjj/� /4.Name of Owner f-j h e/cr rel_.oi Address of Owner: A-T l yci Date of Inspection: y— 27- U0 Name of Inspector:(Please Print) f7 //C '" 1 om a DEP'sppeaved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: /7 fill Lion" �rv� Mailing Address: /12 I'l"a/ti., S 7� /Yo>vt r�is/1i1,�%/s�/-Ic, Telephone Number: CERTIFICATION STATEMENT 1 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 inspection. The Inspection was performed based on my training and experience in the proper function and • maintenance of on-site sewage disposal systems. The system: l // Passes Conditionally Passes Needs Further Evaluation By.the Local Approving Authority ' Fails /. _ 4u s Signature: /�" Date: :(4, .W_S' ystem Inspector hall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the'buyer,if applicable, and the approving authority. NOTES AND COMMENTS -' i14Y r � a o 0& 3 ?00 ,Or revised ,9/2/98 Page Iof11 i,Printed on Recycled Paper l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A' CERTIFICATION (continued) Property Address: Owner: Date of kupection�• �ym �� y- ?7 -GYJ INSPECTION SUMMARY: Check A, 8, C, or A A. SYSTBA PASSES: I have not found any information which Indicates,that any of the failure conditions described in 310 CMR 15.303 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. 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 Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will.pass1inspection if,the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe($) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). 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 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 1i r , s r revised 9/2/98 P2ee2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /�f� R T 1 Y9 Owner: �,[ 01 Gt �PI'•!�in p Data of inspection. y- 27-vo 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. I 1) SYSTEM WU-PASS UNLESS BOARD OF HEALTH DETLMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING W A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy.is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a ;'•.f`?. private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the ;�tt%T• 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. Method used to determine distance (approximation not valid). 3) OTHER - ,, a .. : .... ... . revised 9/2/98 P2ge3of11 m,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 0 Owner: &`!(/A Data of Inspection: D.�.,,SYSTEM FAILS I�T—©O :r You must in either"Yes' or'No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this ._y determinatlon Is identified below.:The Board of Health should be contacted.to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool. Discharge ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 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. T;t •',-_.:;,; ;;,,Any portion,of a cesspool or•privy Is less-than 100 feet but greater than 60 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: 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: The system serves a facility with a design flow of.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 following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply • E. 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 upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further infounation. revised 9/2/98 Page4o[II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTS CHECKLIST. Property Address: "j ad )?r !yq Owner: Date of InspectioneI ``�r"'•"p y-27 CV — Check if the following have been done:You must indicate either 'Yes" or"No" as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health. None of the system components have been pumped for-at least two weeks and-the system has°beemreceivingirormal 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,&&dVdftTg1 a Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓/ _ Existing information. For example, Plan at B.O.H. 87 S_ Datermined in the field(If any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) 115.302(3)(b)) _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :,:i•:.. PART C SYSTEM INFORMATION Property Address: :�;Oo n'T 1 yg Owner: Date of Inspection: 7 FLOW CONDITIONS RESIDENTIAL: . Design flow:330 g.p.d./bedroom. Number of bedrooms(design): 3 Number,of bedrooms(actual): Total DESIGN flow 33r0 V Number of current residents: Garbage grinder(Yes or no):do Laundry(separate system) (yes or no):N,1 ; If yes, Separate inspection required Laundry system Inspected.,(yes or no) y9 g'y�_r�oo .Seasonal use(Yes'or no){!1v 1 .'. ,1 Water meter readings,if available(last two year's usage(gpd): 23�' = �� `�eo Sump Pump(yes or no): A/o Last date of occupancy: Oec-i4pi ld COMMERCIAL/INDUSTRIAL: Type of establishment: ' Design flow: Sad ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PIJW�WG_RECORDS and source of Information: System pumps as pa of ins action:(yes or no)— ..it yes.-volume pumped:___gallons 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other sR�yn� T•.k , �lrac.<�,`� � � Gylr �/ow �PHc� �;� a�'�'L,�.���,`� — T--- APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site:(yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C :.:SYSTEM INFORMATION(comkwed) Property Address: '✓I pO /�T/�!9 /J//�ir3�OhS ��Sr/�is Owner: h/rrpiA rJI•rr iHv Date of Inspection: d�(— 7.7 0 BUILDING SEWER: (Locate on site plan) Depth below grade: a , Material of construction:—cast iron 40 PVC other(explain) Distance from private water supply well or.suction line • Diameter _..... . Comments:(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 T Js.age confirmed by Certificate of Compliance_(Yes/No) _.-Dimensions �/..r`' X 8 Sludge depth: 0-1 • Distance from top of sludge to bottom of outlet tee or baffle: y Scum thickness: C�= Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of qutlet tee or baffle: 17 How dimensions were determined: R� �r 4' A�o4say.:3 iPvo( Comments: . � rw Acommendation for pumping,condition of Inlet and utlet.tees or baffles, depth of,liquid level in relation to outlet invert,structural integrity, y »� `• �0vldence of leakage,etc.) ' .:.i GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene .—other(explain) Dimensions: e Scum thickness Distanco from top of scum to tap of.outlet tae or baffle: Distance from bottom of scum to bottom of outlet tea or baffle: Date of last pumping: 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.) revised 9/2/98 Page 7orll -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C " """L'SYSTEM INFORMATION(continued) Pr-party Address: /f r /hGi /)�/a,i7o•�s /Ni��Sy �. Owner: Data of kupection: L/— 7—Oct TIGHT OR HOLDING 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(explain) Dimensions: _...... ._..._. Capacity:, gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,.etc.) • DISTRIBUTION BOX:N�y (locate on site plan) Depth of liquid level above outlet invert: Comments: gquk if level and distribution Is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) •.�. n�.� di�s� �OY arcs PUMP CHAMBER:_ (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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1;SYSTEM WFORMATiON(continued) Property Address:Owner: 4 �o�,c /�/l,�/s /L1a. Data of kupec ti n: Fir"• .,p ti-27-Oo SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number:2 leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) /I 7'' !� 7,' ryl •s �, 7QHk h4 CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth.of scum layer: Diepnsions of cesspool: Mateuals of construction: Iddi'cation of groundwater: inflow(cesspool must be pumped as part 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: (not@ condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised '9/2/98 Page 9of11 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 'er Owner: Date of Inspection: L1��7--00 SKETCH OF SEWAGE DISPOSAL SYSTEM Include ties to at least two permanent reference landmarks or benchmarks -locate all wells within 100'(Locate where public„water supply comes Into house) ell • '�4 J7, " -30 M � f,s ro c.•,•�- 0Ire �O C✓vr� � p revised .9/2/98 P2gt10Of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION(continued) Property Address: �y9 s Owner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation We11s checked Groundwater depth: Shallow Moderate // Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater do*-"Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole, basement sump etc.) Determined from local conditions !�Checked with local Board of health Checked FEMA Maps _ Checked pumping records Checked local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) wale.." i revised 9/2/98 Page 11 of 11 CEWTERVILLE-OSTERVILLE-MARSTW,7S MILLS • FIRE DISTRICT 1875 ROUTE 28 CEFJTERVILLE, MA 02632 (508) 790-2380/FAXD(508) 790-2385 OILIHAZARDOUS MATERIAL RELEASE FORM F.A.# i LOCATION: ADDRESS OF RELEASE: 20 AA DATE OF RELEASE Z"I(p PRODUCT RELEASED: 1-2 L ESTIMATED 4UANTI`ffldJ �LL)1 CORRECTIVE ACTION TAKEN BY+/RESPONSfijLE PA�RTY: r p��J� r� CPt t t_ ` NOTIFICATIONS: FIRE DEPARTMENT: YES(--f NO( ) DATE: TIME: NATIONAL RESPONSE CENTER YES( ) NO(r')- DATE: TIME: • DEPT.OF ENY RONMENTAL PROTECTION YES( ) NO(v)- DATE: TM: OIL SPILL COORDINATOR: YES( ) NO(--)' DATE TIME: TOWN BOARD OF HEALTH: YES( ) NO( DATE: TIME: TOWN HARBORMASTER: YES( ) NO(,.) DATE: TIME: OTHER AGENCIES- COMMENTS: f tL 194 (.-;f -Ur d r Jr kr?0t F a IL#yilfeAJLJc__ ( re)F nay i�� Yam_ rr Siva t r 14)c, A , e e�l a( r .Clrc�r7` c2+ 1di ll�lL 1� I r f 1.1 � All) d.(,t-a#=114r {-r- Al?;10-4w y r�a t 1 lilt ild 6f is�n r� c r )'" t s 1Cr r (L17�1rjLJ( I, ` --It itn nJ-)- �-) i'+� 4A IZ4 e x)` :=a do 4 1G1-d- /"ram REPORTED BY: Y+''� .., -�' ' DATE: C I�t WHITE COPY-F6P,E DEPARTMENT YELLOW COPY-D.E a. Pff,COPY-1 OMD OF I-EA!TN C-O-MM FORM #59 No- -1!?-:-1 , Fss...2v .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirution for 11ispustti Works Toutitrudion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (/-I an Individual Sewage Disposal System at: 016,0 ---2 :....._..��1 �,.11 ............... Location-Address or Lot No. owner Address --------- - -�'z ..... 4 - Installer Address dType of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Ga 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........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-.--------:------------- ti, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------------------------------------------------------•••---......................................................... ODescription of Soil----Q- :?---••---• •1..................2 ......•4y•=.......... ---------S!t!N......................................... U ..............................................-•-.........•••-•--••---•------•-••-•••--.......••---••---•--•••-•-•--•--•--•--•---•--•------•--.........-•--•----...................-•--..........•.----- ---------------------- ---------------------•-•---------------•--•-•---•-•-•--••••-•••...••-----------••------------------------•----•••--•---------------••-------•••------........ U Nature of Repairs or Alterations—4nswer when applicable...Ate........a-u9.7-.......�I.o.C�......c'� ..................... � t'' z�.......ST3w. ..... g�r3�M� s'tST�r► Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed �� 9 � . •�� �1�. �..... --- ..... Application Approved By ---------------)�s Application Disapproved for the following reasons- ----------- ---- .........................................-----------...................................................... ------------- ................................................-------------------------------------------------------------------------------............................................................ -------------.......................... PermitNo. -------�>0'- ---- .......................... Issued ------------- ------------------_------------------ Dace No.. Fss..... :.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH \ TOWN OF BARNSTABLE Appliration for Disposal Works Tonstnution Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (/kr an Individual Sewage Disposal System at: ................___._ --•- - -------------•------..............--- Location-Address or Lot No. ....._•-•--.....O.H)i!12E. ...................................... ------------...................................................................................... Owner Address a kA\e-_ \<� C'��cJ S� C'O _ ?3 Installer Address Type of Building Size Lot----------------------------Sq. feet U IDwelling—No. of Bedrooms................................ -Expansion Attic ( ) Garbage Grinder ( ) ►U P4 Other—Type T e of Building .............. No. of ersons....._......_._.._........._ Showers — Cafeteria W YP g -------------- P ( ) ( ) ¢� Other fixtures -----------------------------------•------------------------------------------------------------------------------------------------------------------ w Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. IY4 Septic Tank—Liquid-capacity.....•..•._.gallons Length................ Width................ Diameter................ Depth................ w Disposal Trench—No..................... Width....................Total Length.................... Total leaching area_-----------------sq. ft. x _ 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•---••--•----•-•------•---------•-•••---••----••••--••-----•-----------------------•--....-------•......................................................... O Description of Soil....Q.-?._........5 v.(_l-------------------:1. Zr --------.... '.........5 st,�`� x U -----•-••-•-•••------------•-•-------•---------•-------------------•-••-------•-•-•----------••--------------------••--••••-----•-•------•--••--------•---------------••----.....-----•--••----------••- w U Nature of Repairs or Alterations—Answer when applicable___' 49---------?.41�__-_--.C-1-0 ah 'n%t? ....................... ' STa.v .......................................................... � -- . s e5 wr - sti Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed � '� $.. `- Da I Application Approved By ------------- .....�� - Application Disapproved for the following reasons- ............--------- ------------------------------._.......__........................-------------- ------------------- ------------------------------------------------- ---- --------- ----------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- Dale Permit No. ...... ' ;�h Issued ---_------------------�.e-------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH TOWN OF BARNSTABLE Gertif ra a of (gontyli xttce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired(�) by...---t-1-t �c�L k----------c-aw`Q------------c t�- ` .............................. / Installer at --301t) e�T �.�f. ---------- �. ���-------'---------..................................................--------------- - has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. --------5e-:. .®�_. <'�.... dated --_f.......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED SAS A GUARANTEE THAT THE SYSTEM WILL UNCTION SATISFACTORY. DATE. - -- ._.1 ......................................................................... Inspector f� ",'-�--------•--------=------`----''ice THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /�, TOWN OF BARNSTABLE No._.. ... FEE FEE . • -------•--- Disposal Works Tun#r ion Fermi# Permission is hereby granted__=,0 T `., .........�.)...?S`SB.In1 •--•`K,.-,�4_............................ to Construct ( ) or Repair,( an Individual Sewage Disposal System a � � --------------------------------------------•---•-•-••----•-- at No. a12. . 1... . ._..... Z � \� Street as shown on the application for Disposal Works Construction Permit No.__,Z_?.!vL Dated.......................................... ..................................... --------........................................... r l DATE................................................................................ v f oard of Health FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS `'tf TOWN OF BARNSTABLE LOCATION 300 V-OG E l'A 9 SEWAGE VILLAGE Mpj?,S--6j, ASSESSOR'S MAP & LOT HICKEY CONSTRUCTION CO., INC. INSTALLER'S NAME & PHONE NO. P.O. BOX 236 ULNIF-HVILLE, MA 02632 SEPTIC TANK CAPACITY_+D O LEACHING FACILITY:(type) P iTS (size) NO. OF BEDROOMS PRIVATE WELL OR 4UBLIC WATE BUILDER O OWNE DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,� _ 3 � �`� 1 �� � ,,�� ,