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HomeMy WebLinkAbout0356 ROUTE 149 - Health 356 Route 149 Marstons Mills _ — A= 079 -0311 'u TOWN OF BARNSFABLE LocA-I,oN 366 R+e lq ( SEWAGE� v LAc �Vla�s s ,N1 �l S ASSESSOWS MAP&LOT02q JNSTJ ALI.ER,S NAME&PHOME NO. SEP71C TANK-CAPACI xG f yen c4 (six)/006cil I-- NO.OF BEDROOMS__._ BUILDER OR OWNER PERIffDATE: .COPAP DAM Separation Dist=Between the: Maximum Adjusted Groundwater gable to the Bottom Dfl eadhing Facility Feet Private°Eater Supply Well wW Leadung Facihty any webs eat on site or within 200 feet of leaching facility) Feet- Edge of'Metland and Leaching I~aeility(If any wetiands exist within 300 feet 9fileading fa tv) _ Feet uPmished by -c- , s�. Q-�-asp �- , - - - - •® 8-0- 33` Commonwealth of Massachusetts W Title 5 Official l'nspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 `every 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. A. General Information C)-? ,03 I 1. Inspector: t Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name N 29 Atwater Dr -� C c, © Company Addressinx ' E. Falmouth MA 025363 City/Town State C7.) Zip CodeN ¢ 1-508-495-0905 S13971 OD ;a• Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address nd that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally.Passes ❑ Fails ❑ Needs Further Evaluation by the Loca pproving Authority 5-22-08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 II l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Route 149 Property Address Assetl i n k Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D . 11 A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. '- 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 app- ro jed'b'y the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined, please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health).- broken pipe(s) are replaced ❑ obstruction is removed 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public°health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/ day flow ❑ ® 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. 356 rte 149•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ z 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 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 5 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑ 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 of distance is unacceptable) [310 CMR 15.302(5)] 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: 4 el Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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 I Other(describe): i 356 rte 149-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 L Commonwealth of Massachusetts N W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,M y 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12" 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: 6'x6' Block Cesspool Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle 72" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape 366 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Block Cesspool in good condition with all baffles in place. 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): ` Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 356 rte 149-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 356 Route 149 Property Address Assetl i n k Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000Ga1 ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-25'x2' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc..): Leach pit empty at inspection with stain line 30"below inlet invert. Leach line probed but not excavated. 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information cont. Y (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i D 4-0- 33. 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 'l r .f , • `III Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Route 149 Property Address Assetlink Owner Owner's Name information is required for Marstons Mills MA 02648 5-20-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 30' 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: Town maps show groundwater at greater than 30'. 356 rte 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I Town of Barnstable ��FZHE Tp� a Regulatory Services B,ST,BLE, : Thomas F. Geiler, Director p f059. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic Inspecticns.DOC L0 CAtION �J6 Rov7f l,� S W AGE PERMIT KQ, VILLAGE 7u,7 � ` �� 70 A/S N, INSJA LLER-S . N ADDRESS e UIL,DER OR OWNER DATE PERMIT ISSUED SATE COMPLIANCE ISSUED . Z d�� t S� 'S i I i r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION w � C V� Or/ 9 0.3/ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 356 Route 149 Marstons Mills Owner's Name: Priscilla Adams " Owner's Address: x :-j LL" Date of Inspection: 3/27/2006 < r (J-) Name of Inspector: (please print) Patrick T. Sullivan 1 Company Name: Ready Rooter Mailing Address: P.O.Box 371 Q:) Sandwich,MA 02563 Telephone Number: (508)888-6055 -_j CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: L,/Passes Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditiona ass"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. ,r Answer yes,no or not determined (Y,N,ND)in the for thV 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 flank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as pproved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout 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 ter_obstruction is removed distribution box is leveled or replaced ND explain: �f f, The system required purpping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 C. Further Evaluation is Required by the/determies Health: Conditions exist which require further n by the B and of Health in order to determine if the system is failing to protect public health, safety or theent. 1. System will pass unless Board of Hermi es in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannw' 1 protect public health,safety and the environment: _Cesspool or privy is within 50 feeace water_Cesspool or privy is within 50 feedering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water ySAupplier,if any)determines that the system is functioning in a manner that protects the public health,sdety 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,:' I The system has a septic tank and SAS and the SA§'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 analy,sis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitratF nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the�nalysis must be attached to this form. 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _jZ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool t/ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped a/ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] .00O(Yes/No)The system fails. I have determined that one or more of the above criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a farcility with a design flow of 10,000 gpd to 15,000 gpd. / You must indicate either"yes"or"no"to each of the fol wing: (The following criteria apply to large systems in addit�&to the criteria above) yes no the system is within 400 feet of a surf�Vte drinking water supply — _the system is within 200 feet of a t filutary to a surface drinking water supply — _the system is located in a nitroeywell n sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supp If you have answered"yes"to any/question in Section E the system is considered a significant threat, or answered "yes"in Section D above the lar system has failed.The owner or operator of any large system considered a significant threat under Sectionor failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner shQGld contact the appropriate regional office of the Department. i f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health _,Were any of the system components pumped out in the previous two weeks ? ✓_ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the 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 sic 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 than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) I Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 14 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): q(c Number of current residents: i_ Does residence have a garbage grinder(yes or no)::1-->=�. Is laundry on a separate sewage system(yes or no)rtx,[if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use: (yes or no):N--) Water meter readings, if available(last 2 years usage(gpd)): ,o Sump Pump(yes or no):.,L'� Last date of occupancy: C COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq. ft. c.): Grease trap present(yes or no):_ Industrial waste holding tank present es or no): Non-sanitary waste discharged to t Title 5 system(yes or no): Water meter readings, if availab : Last date of occupancy/use: OTHER(describe): , GENERAL INFORMATION Pumping Records Source of information: ,L z) Was system pumped as art of the inspection(yes or no):X<-S If yes,volume pumped d gallons--How was quantity pumped determined? ^c Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval v/ Other(describe): c pne: Approximate age of all components, date insta ed(if known)and source of information: N�cS3� �C V \�1 SJ`� —�•A'�c�, C3-k» �;c.��.��:4a l,-..<�L.O� .. �`,�.<�. �!Were sewage odors detected when arriving at the site(yes or no):-Uej I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction:_cast iron_40 PVC_other(explain): Distance from private water supply well or suction line: Z/V, Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene —other(explain) / If tank is metal list age:_ Is age confirmed by a Ce ficate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from the top of sludge to bottoXorbaffle: or baffle: Scum thickness: Distance from top of scum to top of outlDistance from bottom of scum to bottom baffle: How were dimensions determined: Comments(on pumping recommendat' ns, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence o eakage,etc.): GREASE TRAP:_(locate on site plan) J Depth below grade: Material of construction:_concrete_metal_fibeyglass_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 outlef tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leak#1 etc.): i - 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 TIGHT or HOLDING TANK: ;ng must be p ped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_contal fiberglass_polyethylene_other(explain): Dimensions: Capacity: Design Flow: Alarm present(yes or no): Alarm level: Alarm in er(yes or no): Date of last pumping: Comments(condition of alarm anhes,etc.): DISTRIBUTION BOX: (if pre/to ned)(locate on site plan) Depth of liquid level above outlet inve Comments(not if box is level and distr equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): 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 cham er,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 SOIL ABSORPTION SYSTEM(SAS):—Az(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches.,number, length: leaching fields,number, dimensions: _;/overflow cesspool,number:I innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): 1 �°�G.T 'lcl'.� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: 'boll Depth of solids layer: 3 Depth of scum layer: Y'' Dimensions of cesspool: S' z Materials of construction: Indication of groundwater inflow(yes or no): Q 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,signs4draulicure,level of ponding,condition of vegetation,etc.): i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. Q' r j ! 01 f Page 11 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 356 Route 149 Marstons Mills Owner: Priscilla Adams Date of Inspection: 3/27/2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water' c feet Please indicate(check)all methods used to determine the high ground water elevation: _/Obtained from system design plans on record-If checked,date of design plan reviewed: 12 5 � 5 /Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) ✓ Accessed USGS database-explain: rf...._.,��r_ c, � . -3, v.. You must describe how you established the high ground water elevation: Jr- Ara �-0-�'zM.- r✓�.G�t�..�'�..1�-G- r�.� r 3 w� i'V�•.A G v IJ n©•J" C,©v.,U-�•rr��� �'-,--B�S�p� „p�E3.1'-- � -�C� Ln�.P�- � 1 �':� ? foz �- TOWN OF BARNSTABLE �LOCATI-rN o VZ. SEWAGE # 357 o `?C>'�r VILLAGE CY�Ar Cc�vL� "y�\S ASSESSOR'S MAP & LOT D;9 03 ? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �;4 Cyr Sbeet, (size) a msag QA1 -NO.OF BEDROOMS BUILDER OR OWNER �t' <-L S 6- 3 PERMITDATE: COMPLIANCE DATE: i� 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 TS O _ a O L'0 t,'A'',$ IONN d S WAGE PERMIT NO. '50� R007 C 70 -T VILLAGE �M A fZs�c�ys M rL� ALL ER'S NAME L ADDRESS Lv B U I L D E R OR OWNER DATE PERMIT ISSUED 10 DATE COMPLIANCE ISSUED �� _ � 7g�- f �r ` a i 1 aq` BLVx tics REA R 7pwN H-�-O f , d L0CAlION SEWAG. PE-,RMIT NO, VILLAGE LNSTA LLER'S NAME & ADDRESS N i. e U 1 L DE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ,. , t_ ?� w 'r r i c � l K V� J �, :�- � �� � f � �' � �" � ' o ;Z9 031 08 THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH ...OF............ ..A ppliration for Ui ipau al 10orks T mitrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (�) an Individual Sewage Disposal tem at: Sys . -� Locat Address or Lot No. ` �! :a-�. .t:...._....- .... ..................... ------ -•---------- -----............__.......-- Owner d ess v- a .......................... ...: _... . Installer Address UT e of Building Size Lot.___�Q_C�l_'.�......Sq. feet Dwelling—No. of Bedrooms_____________3.......................Expansion Attic ( ) Garbage Grinder (k4— '� Other—W Type of Building ---------------•--...---•-•- No. of persons..................._------- Showers Cafeteria ( ) Ote t ---------------••-•-------••------------•--...••----••----••••••------••-------•---•--•.......... W Design Flow______ __ ._: .................gallons per person per day. Total daily flow...n....3`__.0.........................gallons. Septic.Tank— iquid capacity_/6egallons Length................ Width................ Diameter................ Depth................ W 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. 14 ,..`_.minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Lc, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----...........-----------------------_-__---------_-__-------------•-----------•............ ODescription of Soil----- ------------------------------------------•---••------............................................ w U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------------•-----------------------------------•••-- Agreement: - - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with - the provisions of iITL E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee.. /issed by he board of health. D Application Approved By......... :...................----------•--...-----•--•---••. Date Application Disapproved for the following reasons-----------------------------•.------------------------•-----------------•-------•---------------••••-----•------ ---------------------------------------------------------•------------------------------•--._...-----------------------------•----•------••••--------•-•••----•---•-•--------•-•-•--•-•--...------•----- Date Permit No.......................••- -._ --•----------------------• Issued...........-----------------.._.....------ ---•-- Date r i 1 FEs......� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTLJ OF............... .... .. ..._........ _...:.: ............ ...........__. Appliration for Diipoaal Work i Tonstrn.rtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (A an Individual Sewage Disposal Sysat• ........ .. ....... ........---•................. ...._f ___&''4.... . ... ocat' --Address or Lot No. ....... ........................ ....................... -• ••--•.............. f Owner W . . 1< ess y Installer Address T,Veof Building Size Lot____ Q .....Sq. feet U Dwelling—No. of Bedrooms______________ __.__-____.-_----------Expansion Attic ( ) Garbage Grinder ( � aP Other—T e of Building ._.___ No. of ersons............................. Showers Other—Type g --------•------------- P ( ) — Cafeteria ( ) Ote, xt ------------•-------------------------•--- ---- W Design Flow.... .__ ._ it_�....................gallons per person per day. Total daily flow..__��.__�_0.........................gallons. W Septic Tank— iquid capacity. Disposal Length................ Width................ Diameter................ Depth................ x Disposal Trench—No :_t________________ Width___ _._ ......... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........C-__.... 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........................ f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - -- • - --•--•------------------------ 0 Description.of Soil........ _. ---- ------ - -- t UNature of Repairs or.Alterations Answer when applicable ___________________________________________________________________________________________ ---•••_.._..•••-•-•-•••••••--•......-•-•-----------------•-•---•--••-••--------•--•-•-------.......•-•-......--•--------•---•••---•----•---•••----•-••-•-•--•-•-••••••----•------------.....__...----•• Agreement: The undersigned agrees to, install .the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTIS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beerdiss ed b he boar of health. „ ,r✓ ` Da e Application Approved By... � -- �. ........ _ .. '................... ...........................��` . l-�.. t . ..... .�• f Date Application Disapproved for the following reasons:-----------•---•-•-------------------------------------•------•----------------------------------------•--•••--- --•......................•---•--...._.._..--•------------------- •-------------........------•-----.............-----------------------------------------------------------------------------••-- ..... .......................................................ate Permit No...•-•............... ----- -•-------. Issued Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :. (9rrtifirab of Tontplianrr TH IS O CE IFY,�TtheInd.,vidual Sewage Disposal System constructed ( ) or Repaired ) by ....- Installer .+.. at ` - r ----------•••--- has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the application'for Disposal;Works Construction Permit No.___. �--' _'. 1 .��_____ dated------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... -•-- • - -- ................... Inspector................. ...... r THE COMMONWEALTH OF MASSACHUS TS BOARD OF HEALTH � - Rog ..........................................OF..................................................................................... ( � No......................... FEE (-•• �is�ro�tt ork� one nr#Uq �erntit 1 Permission is hereby granted........ ...... -----------------•--•--............................................ to Construct o r. f a �Idwidual wage Disp ysm 19 �G- l at ....... . 0 .. Street t as shown on the application for Disposal Works Construction Permit No�_��_�- Dated........... .................................................. Board of Health { DATE........ �� -•-------------------------••--•--_.._. 'C: Sum FORM 1255 HOBBs &~WARREN, INC P_X3LISHERS