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HomeMy WebLinkAbout0661 ROUTE 149 - Health r -661 Route''149. A= 101 =001 "Marstons Mills' . l S M E A D No. 2-153LY UPC 12934 smead.com • Made in USA �,CY °`I. i ' ; '0; ROM USED M TH5 PWDUCT LK S F I AUM TK SOUR MG iE0U11Eum OFT1*SRFRDWM CERfIFlED SDURCJNG NrM WAF F406RWORO i` \ TOWN OF BARNSTABLE LOCATION 606 /ROV t-( l -t It 41 41 SEWAGE# VILEAGE VI-1 yr, ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER j PERMIT DATE: 10 I t,t fAsf)7` ,CI&MPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Commom yealth of Massachusetts • y Title 5 Official Inspection Form.;+: .; Subsurface Sewage Disposal System Form-Not for Voluntary Assessmenfs� 19) Merstons Mtlls,MA 02W - - - 661 Route 149-CoNN Road•P.O.Box 736,._ vropeNyaad,sa . Madden _— omws owners Name MA 02648 10I112012 ia—tion o Marston.Mills .....__.-_.._....._..-.__.__ Code oam of tnspatllm, ,epimed far are,Y ....... State_ Lt? pa" CdyRwm D.System Information(cunt.) 1 system.including t es to Sketch Of Sewage Disl o l System:Provide a view of the sewage di all wells Y. 11Y at least two Pemfanent rete2nce thedmarks or benchmarks.Locate all elo whin 100 feet Locate whJ�Ia public water suPP1Y girders the building-Check one of the boxes below Q hand-sketch in the area below Lady��1+� ❑ drawing attached separately n-v- L J-ov (�3 a-9.�:, y� ti, ✓ o tt�f� � � P �* p� c S� y, 3 8.5 �S, � f r i � 3`I� y >. : 30' d G 0 LO CAT IO , SEWAGE PERMIT NO•✓ VILLAGE INSTA LLER'S' '' NAME i AD-DRESS �LUS 9 NLd� e C4'r�7� r 'li✓�5 7 f " -BUILDER OR OWNE }` DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED /z �y d h { I 1 No.... r�t.:.�6�' t f FEs...V�....� .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F.......................................-------------------- l� Applira#ion for Pisp.asal Murks Tomarnrtinn Vamit Application is hereby made f r a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a ' ... fi.l--..... . .-- ti ` ..... . ...(...............................••------ ------..------------.............------•. ocat - dress or Lot No. •- ._.... � 1 .... ............................................... •-•---••-•----.....---•--•----•.Address ................... Installer Address �l - S � Type of Building Size Lo ._._..,�!�!Id......_..._. q. feet Dwelling—No. of Bedrooms........... ..............................Expansion Attic ( Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Gd Septic Tank—Liquid capacity]SU.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width....o':J........ Total Length.....'-...... Total leaching area..4.�......sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY........................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---•-••••--••---••------•---•--------•-•..............••---•---••----•-•................•--•-............................................................... O Description of.Soil........................... C . ..... U •----------•-----•.............•-----------------------••------•-----------------------------------......-•-•--------------•-----------------------.........-•--•---•-----...._.................-------- W Nature of Repairs or Alterations—Answer when applicable.... --- ------------------- -- — of r..0 - .. .. ----------------•-.....--•----•-•-•--•---•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI:`'TE 5 of the State Sanitary 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....... ` atikV1. .-...:. ... ,..... D.te._.._..._..._ Application Approved BY c: ....... "----------- Date Application Disapproved for the following reasons:.............................................................................................................. ....•----------------•-----.......----------•------•-•-•------....•-•----•...••---------------•---.......•-------•----•-•--•-•------------•-----•••------••••-•-••-••••-•-•••----•••---••---•••-•---•--- Date Permit No.................•--...........----•-----••-•---•--- Issued_....-----...--- . ---• Date------•--••-----------•-------- r r No.. .. ..... .. ............................ THE COMMONWEALTH OF MASSACHUSETTS " OF HEALTH "BOARD ....................................OF.......................................................................................... Appliration for Dipposal 10orkii C mitrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or-' Repair ( ) an Individual Sewage Disposal system t . ..: .. 1 :.. �� 5 / -• ._..._. ..... ...._. r �._ ..._... ...... ... --. ---.-_. ..... " oc ddress "• or Lot No. � ne Address y...._.c� .. ------------------------- . ....... J Installer Addr � D Type of Building �' Size Lot............................Sq. feet U Dwelling—No. o„� Bedrooms......................................._....Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons......................._----- Showers — Cafeteria 04 d Other fixtures -------------------------------------------------------------------------------------------••-----------------•-•--•---•--•••-----------••-•-•-••---- W Design Flow____________________________________________gal lons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity._._1.5D_0allons .kngth................. Width___p.._.___.. Diameter................ x Disposal Trench—No..................... Width_. .___.._. Total Length.___..L__:__......_. 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............................... .... Dafe........................................................minutes Depth to ground water......................... ( , Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_--_____-______________- 9 -----------------------------------•--•-•------------------•--------•---...-•---•---........---..._......_........-----......_.._.._.__._......•-••-•-.....-- 0 Description of Soil............................a Lck....- ---------------------------------------------------...........------------------------._.._....-•----- V :.. -------------------------------------------------------------------------------- ------------------•--------- --•----•------- U Nature of Repairs or Altera ions—Answer when applicable...._____ ©_Q_(43.4-____-__��? j�_._ pt1C„__. —_________- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TiT S E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beano issued by the bo rd , h Signed -... ... ea `b ....----•.................�_ ---------...... :_..:__.....-- •-••---------------..._..__-... , .� ,O)L Application Approved BY.......�'-•'""" �-_----�*'- ' ..... ----�•- .................. Date Application Disapproved for the following reasons---------------------------------------------------------------•----------------••---------..._$4...... --•--- --------------•--.......---------....----•--•------------------------------------•----•-••-------...--••------------•-•••--------------•-----•---------------------------------•----------•------------- Date PermitNo............................................ Issued--•----•-••----•--••----------•-••--••-•--••---••--•--- Date ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............................I.......I...OF...................................................._..........:.._......_......._... Trrtifirate of TI-Impfiatta THIS-Jt�TO ��, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.............---••.�-•--...-------•--•--._.......-••---•--••-•••••••-••-• --••----•---------••-----------•Y•-••--•••-----•••................................................................... at.------. ...... .........;��--'-----I®-'�_�� ----------•-----------------------•-•----------------•---..........__.------------ has been installed in accordance with the provisions of Tl'�;I�y' 5 of he State Sanitary Code as described in the application for Disposal Works Construction Permit No.5�±�_-`�GI.......... dated.........--------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED S GUARANTEE THAT THE SYSTEM 1NIL FU TION SATISFACTORY. 2 � ter. DATE......l. .�1�. Inspector ......................... ------------------------••----------- ✓ s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �}r} No......................... FEE........................ ghlposa� r �oa� #r ion pruti Permission is hereby __rante °------ -_- to Construc or Repair ,- an Individu ewa e.Dis .0 Syst at No.......... --....s,.._.� -.�- -••.d--P� ----0 44. Street as shown on the application for Disposal Works Construction Per-mid No..................... Dated.......................................... -"' -------'-�---.........` -----------------•-•---.....-----._ Board of Health DATE............................................................................... _ FORM 1255 HOSES & WARREN, INC.. PUBLISHERS n 4 h/ipr'J 81/ti s /moo.•--� \ ELL 20.oc �ASsvmE�) . 1 1�� 'f" ► Gg . � I L Ik ' rn 1\ k i FX/5T/nv¢ 0 - _ ®� sEPrlc ` W,4TER L"Elic L 2a ko u i A;'P2ox. 2 r pv��P • C/lAMR6 vo 7L° _ V" BOTH B�/�D/NHS A2E CLo5�=2 7o SRO t ,C oT, L/n/ES 'TW,4n/ �F9 v�/ZFD uvvF/Z P.eESE�T ZoNiiv� ay- LAW �! 0pa 7-0 2s 7G — CERTIFIED PLOT PLAN IN - .. C�E'�/AT/oNS� a.4sF� ON_ Wi9r�/Z /ylA/jSTONS�j�/ccs �,�SS i L,�vEc -f>/A�YJgL/NS Po/✓D • S-,Z- PZ BE/�v� �Now.�-d.�•'pc. BK• //S 7/ IRA R.THACHER, JR. REG. LAND SURVEYOR B.s��.�sT.v�scF ,yF.s'crs ENr' SO.YARMOUTH , MASS. t DATE G- / - g Z SCALE DRAWN BY /nT' SHEET/ OF 2 o f A�+ ss. 1 CERTIFY THAT THE F-A' s JfJ•'� � ., o IR ✓i q e��Lo/NyS SHOWN ON THIS PLAN . RICHARD yG , JAMES � r � N CONFORM TO THE ZONING BY- LAWS -+u NoIf694 - + .!z3S'14 OF THE TOWN OF B/��� sTAac� c�cEoT 11 _ No. 69� O cn /� O FFv lqG/STE�y0�1 �S //oi ED. Di �%f REG. LAND SURVE OR 1MF T Town of Barnstable Barn ti Regulatory Services Department A&AnMftCHY BARN5TABM 9�"`" Public Health Division i63y. 1�� m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Interim Regulatory Services Directoi FAX: 508-790-6304 Thomas A.McKean,CHO August 29, 2013 RE: 661 Route 149 Marstons Mills A=101-001 All repairs ordered in the November 6, 2012 Board of Health letter were completed as of February 25, 2013. Sincerely, Donald Desmarais, R.S. Town of Barnstable Public Health Division 508-862-4644 Fax Send Report SEP-17-2013 09:16 TUE Fax Number • 15087906304 Name BARNST HEALTH Name/Number 915084203161 Page 1 Start Time SEP-17-2013 09:15 TUE Elapsed Time 00'12" Mode STD ECM Results [O.K] Town of Barnstable . Barnstable Regulatory Services Department ' UANNdI'ANI.k. ' I I Public Health Division 200 Main Street,Hyannis MA 02601 2007 O iee: 508.862-4644 Richard V.S-Ii,huhaim ReplaWy Services Dirw fAX 5014-740-6404 Thomas A McKean,CHO August 29,2013 RL:661 Route 149 Marstons Mills A=101-001 All repairs ordered in the November 6,2012 Board of Health letter were completed as of February 25,2013. Sincerely, Donald Desmarais,R.S. Town of Barnstable Public Health Division 508-862-4644 COMPLETEE.R:COMPLETE THIS SECTION • ON DELIVERY s Complete items 1,2,and 3.Also complete A. ' nature item 4 if Restricted Delivery is desired. X _ ❑Agent ■ Print your name and address on the reverse. ❑Addressee so that we can return the card to you. B. Receiv by Print ame C.rte of De■ Attach this card to the back of the mailpiece, a y or on the front if space permits. D. Is delive address d' a �446m 1? ❑Yes 1. Article Addressed to: s If YES enter d$jiyery address be dW: ❑ No,; Mary,.i Madden P O Box 736 Marstons Mills, MA 02648 3. ServiceT ❑Certifled Mail ❑Registered ❑R ec r Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Y 2. Article Number �� 1 l 7 0 0 - �0 8`10 0000 i 3�5 2 4 7 4 3 (Transfer from service label) Ps Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SRVIC First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • r Town of Barnstable Public Health Division 200 Main Streety Hyannis, MA 02601 _ Town of Barnstable Barnstable pFVE Tpw Regulatory Services Department Al- "'e'taC " + nARN5TA6LE. 'I I v MASS. Q Public Health Division 9e '67 9 `gym 7 -O rfD MA'I a 200 Main Street, Hyannis MA 02601 ���� . Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3524 7434 November 6, 2012 Mary C. Madden P O Box 736. Marstons Mills,_MA 02648 The septic system located at 661 Route 149, Marstons Mills, MA was last inspected on • 10/11/2012 by Reid C Ellis, a certified septic inspector for the State of Massachusetts. Under the guidelines of the 1995 TITLE 5 (310 CMR 15.00), the Health Division has determined that the following repairs are necessary for the system to be in compliance. • Metal covers need to be replaced. • Sand needs to be,pumped out of the septic tank & pump chamber. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH omas McKean, R.S. CHO Agent of the Board of Health • Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\661 Rte 149 MM.doc Commonwealth of Massachusetts Title 5 Official Inspection Forrrm ,,fi.*,9 . is Subsurface Sewage Disposal System Form-Not for Voluntary AssessieF)s'`�' 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648T — Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Reid C. Ellis use the return Name of Inspector key. Ellis Brothers Const. � Company Name 23 Enterprise Road, P.O.Box 59 Company Address Yarmouth Port MA 02675 Cityrrown State Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification 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 16.000). The system: r-1) —i ❑ Passes ❑ Conditionally Passes ❑ Fails (7) a Needs Further Evaluation by the Local Approving Authority 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. t5ins-11/10 Title 5 official Ins o f rtn:Subsurface Sewage Disposal System-Page 1 of 17 U _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page_ Cityrrown State Zip Code Date of Inspection B. Certification (cont.) , Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information whichTndicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.31)4 exist. Any failure criteria not evaluated are indicated below. Comments: 64 3� i e L&t 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 mpletion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determin d" (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 e I tration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it i structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less th n 20 years old is available. ❑ Y ❑ N ❑ ND(Explain elow): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. City/Town State Zip Code Date of inspection B. Certification (Cont.) B) System Conditionally Passes (cont.): a ❑ Observation of sewage backup or break outr high static water level in the distribution box due to broken or obstructed pipe(s)or due to a b okn, settled or uneven distribution box. System will pass inspection if(with approval of Board of Heaelth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replac ❑ Y ❑ N ❑ ND(Explain below): s ❑ The system required pumping more than 4 mes 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): C) rther 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner information is Owner's Name required for every Marstons Mills MA 02648 10/11/2012 page. Cityrrown State n Zip Code Date of Inspection B. Certification (cont.) - 7 2. System will fail unless the Board of ealth (and Public Water Supplier, if any) determines that the system is functioni g 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 tribut ary to a surface water supply. ❑ The system has a septic tank and 3AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and 3AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS zini i 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 analysJl , performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the preence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fure 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 t5ins•1 vto Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s)- Number of times pumped: ❑ L 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. ❑ 1� 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 P pp y well. ❑ Any portion of a cesspool or privy is less th an 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 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 syste the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate eit er ` c ,to ea ch of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 40 feet of a surface drinking water supply ❑ ❑ the system is within 20 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 map ed 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 [arc a system has failed. The owner or operator of any large system considered a significant threat under ection E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. he system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is — required for every Marstons Mills MA 02648 10/11/2012 page. CitylTown 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, luding 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts u Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes VNo Laundry system inspected? ❑ Yes Seasonaluse? ' Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: e-o C;ps AL Sump pump? ❑ Yes No Last date of occupancy: � i Date 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 Industrial waste holding tank present? • ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 sys m? ❑ Yes ❑ No Water meter readings, if available: t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Dis posal sposaf System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? —&Kes ❑ No If yes, volume pumped: ' gallons — How was quantity pumped determined? Reason for pumping: Type o ystem: 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): t5ins-11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal sposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owners Name information is required for every Marstons Mills MA 02648 10/11/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes I'J No Building Sewer(locate on site plan):Depth below grade: l p :3 0 feet 7Mate ial of construction: 6 ,�/ cast iron �� IM 40 PVC ❑other(explain): / Distance from private water supply well or suction line: 1 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Mate al of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) If tank ynir list a years I aged by a Certificate of Compliance((attach a copy of certificate)J ❑ Yes ❑ No Dimensions: INK — 0 Sludge depth: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736 Marstons Mills MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness L15) Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Own (AJO, 46- ,� (b S71 Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal Efiberglass ❑ polyethylene El 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 oi itlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. Cityrrown 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.): Tight or Holding Tank(tank must be pum d"at'time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal E,fiberglass ❑ polyethylene El other(explain): 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 swit hes, etc.): *Attach copy of current pumping contract(r quired). Is copy attached? ❑ Yes ❑ No 15ins-11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 11 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owners Name information is required for every Marstons Mills MA 02648 10/11/2012 page. di:Wr own State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate o site plan): Depth of liquid level above outlet invert /v Comments(note if box is level and distribution to outl equal, any evidence of soli rryover, a evidenc eakage into or out of b x, etc.)- L dT Pump Chamber(locate on site plan): Pumps in working order: VYes s ElNo Alarms in working order: ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i J 4j42;�-- Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 44. l j 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w� 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owners Name information is required for every Marstons Mills MA 02648 10/11/2012 page. CityRown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ 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.): Al 12 $ a Cesspools (cesspool must be pumped ae p/nspection) (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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments M . 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 7hand-sketch a public water supply enters the building. Check one of the boxes below: in the area below ❑ drawing attached separately 9V r; V s 15� c°fit la � g 3(0� p: ClrlAw�(ay , 3 9.4; _.. r 30' � �Q "X !Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Mary C. Madden Owner Owner's Name information is required for every Marstons Mills MA 02648 10/11/2012 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope a& urface water � 4,0.� ❑ Check cellar ❑ Shallow wells AJ/A yl Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) W Accessed USGS database-explain: oil b a� Yo)u must describe how you established the high ground water elevation: Alt A � JA Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts IPTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 661 Route 149-Cotuit Road, P. O. Box 736, Marstons Mills, MA 02648 Property Address Ma!y C. Madden Owner Owners Name information is required for every Marstons Mills MA 02648 10/11/2012 page. City/Town State Zip Code Date of Inspection E. Report Completeness'Checklist inspection Summary: A, B, C, D, or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)completed 13 System Information—Estimated depth to high groundwater [! Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 SO) L TEST ,��� �r . � . CJ� A ; � �y / / >V/ VEIRT cG � ✓,� 1 J �y .� TFST I 8z PT) C i TRNK - 0 -- NUNrBE OF BFDRDpI^� - 2 Nv F 80/ ) DING 22. 5 GARBAGE D)SPOSA i.: JNIT NO INC. E T SE PT tC TANK 22 .2 TOTAL EST) MATE'D 4-L 0w OUT I"E T T3 i_ ilN K 22.0 I 0 GAL ,/BA.,DAY 2 B.R .) _ 2 LO GAL,/DAY ' NLFT PUMP CHAMBT-h ai RE U) RED SLnTIC- `Y = 330 GAL OUTLET PJJl,^ i' CHAh) BEA 270 /lCTJAL, SIZE 0 PT INLET Di - r 20 >( TANK TO BE /N414"L I ED _ ) 000 GA L 0 0 T L E T DIST- 5OX LEACHING AREP ," � C� v/RF_ M9 ' NLE LEA LHI ,'vG 7-;eE41ci-1 30T,rG"N,; A/gFA 1. 0 GAL./S.F, BOTTOM OP L.FALHj/VG 7.FEA16H 4, .00 L.F A H l !v S 7 CEACW CAA PA C I T Y = OR O G A L PF SlrFSVE Lt AC HJNU- CAPI9 CI TY = ZOO SA L VARlA CE S REQUIRED -- - i '�CE FROM RAC U ) MiN EC UI .�iEI�^ `�� 7" - —O D05E r' IN I.S A411v FROM P �. Y O,9 STREET �. iNE VOLUME IN COBIc ,FEET /N PUNP CHAAIIBE ;-{ TO 7 STATE SA _1 �D E ) BE PUMPED I1J A D!A Y IZ Zo / '%/Z'�I 20 C.U. FT/D�SF YAi�IANC5 FFfOM R E Q �D ' F1-3J)"1 YOLVA4E IN GALL C,W S TO BE PUMPED 1=GCl/✓Dtt 7-) v f,/ ,�✓kLL I AV ,� Df; y 20 GU. F7" 7:48 G.AL / G 1l l= T = I50 GA L STATE SANrTH� Y LODE ) ACTOg2- S / 2E OF CHAMt3E }i TO 8E IIV5TALLED = .300 C.�,, ji//,'/Y 'F FROM F� L Q L' t � E V E 5` ( SEC . 7 STATE SAN / TAPY 7: 02Sr_=,e vlEF) '"On , r Ol FOUwUFrT/ON h NJHNHU... - ,-L = 24. 5 ?4" DIf;1YlET•� ',--�. �tr; Nt*O't_t. +=�tl�� � U/AMETF F R A•I*vl E TO % GRADE All". 1 T id TN Z 11VCrlFS -� ' 2 iNCHE _ 0 " Y 4 ' D0J8 r N GhADE GLADE F0FnATFD )NCB 1_AY~=R vF C i' TO N E _ f I - - - t,/c T BMX ' M YEN TFi; F-T — 300 GAS P0A,')r . (: 6ER � Iit_- -;E TIC rlIN r v (U� t ; -v��!;�;^ I I E J)!l� . T G R `U „ D VvaT E R TPB L E E L = ca. 0 Y t? ALL �PlP ;.BALL EE 4' S' 'N 40 PV F) P - VV)TH T4E EYER1- O� THE PFOF-' LE OF, 011TI-ET PIP & FROM THE l,Ltf1 P �� y`V.AGr �i 5 AL T E.NI b NOT 70 5CA L. L) SEPTIC TANK SHALL bF VvhT `t R T'SCHT . �N � Y -~. {'--`_ �. �.'= �.z✓s 1 G`-t T Y T�� _ �,;,,,,. yc���7` �f�2 ti STD,�� - - �p r✓ �' `'� :� t;T_� ; Cs fir eft ANV'\ SCAIE;/�5/�/C� TED APPROVED 9Y DRAWN BY T l ! EARN b DATE: G Z I DRAWING NuMe% 1'nRAl EPOS'T1SAS-1/E