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Home My WebLink About0071 SANDY VALLEY ROAD - Health 71 SANDY VALLEY, ( A = ) 01 -- 1 D9 y 1 r Commonwealth of Massachusetts /� P w^m? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tr°a 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name F Tt information is x• required for MARSTONS MILLS MA 02648 9-12-15 every page. Cityrrown State Zip Code Date of Inspection .w C0 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name YQ P.O. BOX 145 Company Address CENTERVILLE MA 02632 few Cityrrown State Zip Code 508-420-4534 S14297 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 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-12-15 41spectl6es 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 . 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 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS THIS REPORT DOES NOT PREDICT HOW THE SYSTEM WILL OPERATE IN THE FUTURE UNDER THE SAME OR INCREASED USE B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): . ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 1/day flow t5ins•3/13 Title 5 Official Inspection Firm:Subsurface Sewage Disposal System•gage 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every 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: ❑ ® 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. El M Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 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 in® El Was 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 per assessing DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D-BOX AND A 1000 GALLON LEACH PIT Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d SEE BELOW 9 ( Y 9 (gP ))� Detail: 2013--------187 2014------156 GPD SYSTEM IS NOT DESIGNED FOR A GARBAGE GRINDER Sump pump? ❑ Yes ❑ No Last date of occupancy: 9-12-15 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 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Citylrown 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? ❑ 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: SYSTEM APPEARS TO BE ORIGINAL Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: .75 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owners Name information is required for MARSTONS MILLS MA 02648 9-12-15 every 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 MODERATE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? SCOUR POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING TANK FOR MAINTENANCE. TANK LOOKED TYPICAL FOR ITS AGE WITH SOME SIGNS OF SLIGHT CORROSION AND EXPOSED AGGREGATE. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface -Sewage Disposal System Page 10 of 17 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owners Name information is required for MARSTONS MILLS MA 02648 9-12-15 every 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 pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): BOX WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION WAS VIEWED BY CAMERA. LOOKED TYPICAL FOR ITS AGE WITH SOME SLIGHT CORROSION Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 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 �M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): PIT HAD ABOUT 1 FT OF LIQUID AT TIME OF INSPECTION WITH A CLEARLY EVIDENT STAIN LINE AT 4 FT FROM THE BOTTOM OF PIT. SOME EXPOSED AGGREGATE 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 t5ins-3/13 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 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Cityfrown 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 where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every page. Cityrrown 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: GREATER THAN 4 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts u ti v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 SANDY VALLEY RD Property Address VERNON COSTA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-15 every 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 ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABL LOCATION SEWAGE((# VILLAGE �� SSESSOR'S MAPI&�0d0 'L3 INSTALLER'S NAME&PHONE NO. J� SEPTIC TANK CAPACITY Ibb LEACHING FACILITY:(type) -1y (siu) NO.OF BEDROOMS !' �` BUILDER OR OWNER Z rA PERMrTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 fat of leaching facility) Feet Furnished by �eC h p�Ct 4 � a tS g A a� AID 1 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=101109&seq=1 9/21/2015 — - n w No......................... FEB............_............... THE COMMONWEALTH OF.MASSACHUSETTS BOARD OF HEALTH Toym . .... . .......... OF..Barnstable 1 Apli trathili for Biip.aiitt1 Workii Tonstrnrtiun Prrmit Application is hereby made for a Permit to Construct (K ) or Repair ( ) an Individual Sewage Disposal System at: Marstons Mills, Lot... .34... r�sr...V. .le�t..Rd....................... -....----------------•----...._.....---...---.....--•--•-•------- Location.Address or Lot No. •--.--Capricorn Realty Trust •76.5 Falmouth Road,••_Hyannis...................... • -•••--•----•--------------- •• ........... Owner Address Steve ................................................ Lebel ............ ...........••----•••••-•.......---•--•---....-•---•........................-•-••••--------•---_... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...3.......................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building rz=la.............. No. of persons............................ Showers (2 ) — Cafeteria ( ) a Other fixtures .................................. W Design Flow........5.. ..............................gallons per person per day. Total daily flow.........33Q...........................gallons. WSeptic Tank—Liquid:capacity1.0.00.gallons Lengtl8_!.6"...... Widtl4.1.1II".__ Diameter................ Depth5'.8....... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit Nol------------------- Diameter.....6....__..__. Depth below inlet..... ............ Total leaching area---2.6.6.......sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by... ............ Date...11--2-5_-81.............. Test Pit No. 1.2...11......minutes per inch Depth of Test Pit... 2............ Depth to ground wateflOne...PMCOunter— Li, Test Pit No. 4I/A--------minutes per inch Depth of Test Pith/A............ Depth to ground water..N/A------_----- e a •--•-------------------------------•---------....-•----------.......---••---.......--•-•--------............--•----•--------•-.........._..._..._...•-•------ 0 Description of Soil..........0-.----•-___2...........loam...&.___t.opsoil......................................................................................... x 1-Q-1.•-••-•IYiadlum••3�ellaw...s-andd............................ . .... . -- . . . --- -- W --- ---- - ............................1-0. .... Md.*----whLte...sandltraees.--ax---gramel/no..water...at.12' 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h s been issue by t board o Ith- .Signed...... � _. .... •-- -- - i Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons_______________________________________________________________________________•--........_.........-•-•------••- ..•-----------------••-•--•-•----•••---•---•---•-•-•---•---......--•••---.....-••••••-...._•--------............-•••......_..••.....----...-•---...••---•--•----•-•••-•------•-•-----•----•----••--•---- Date PermitNo......................................................... Issued........................................................ Date _=------ ----- - - - - - -- --- --- - - -- -- - --- - --�— -&_- ,i No................_....... FEs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town .................... : op...Barnstable A.ppliration for Biipuial Workii Tomitruriiott frrutit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Marstons Mills, .......Zot- 34...amay..Yale.ey-- d...4................... I!Moalm.#...tA-----------------------------•--••-------••-----••-----•--------. Location-Address or Lot No. ........Capricorn.Realty._Trust _765 Falmouth Road,,___Hyannis - •• - .....-----•----- ••• ----- ..._..... Owner Address W Steve Lebel Installer Address Type of Building Size Lot............................Sq. feet v Dwelling—No. of Bedrooms...,3......................................Expansion Attic ( ) Garbage Grinder ( ) Other.—Type of Building ranch............. No. of persons............................ Showers (2 ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow........5....:..........................gallons per person per day. Total daily flow.........33.0..........................gallons. WSeptic Tank—Liquid capacitylOOO.gallons Lengthy-'.6"...... Widthk'.1 Q".. Diameter................ Depth .'. ....... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. l------------------ Diameter.....6............ De th below inlet....b_�___.___._._ Total leaching area __....s ft. ,� Seepage Pit No p a q. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..-El.dz'@dge Engineer111g----_•••-_• Date...11-25-81 aTest Pit No. 1..2..Q......minutes per inch Depth of Test Pit...1,2........... Depth to ground watetnQna...enc-ounter- rX4 Test Pit No. 2I/A........minutes per inch Depth of Test Pitivk----------- Depth to ground water..iV/ _____________ e ------------------------------------ -------•--•----.-.-................ •........................................................................ O Description of Soil..........Q•.•••---•.2•.•-••••--••1ia.aI 1iaaM..&__t.QPs.oil......................................................................................... W 29...--•-10 .ReAlum_..yell.Q.t---$and----------------------------------------------------------- ------------------ --------------------J_Q 12- med wklite...sandlt aces Of gravel/no._.wa er at 12' VNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. /1 Signed....................•--------------------•-------------•--•-•------•--Pres. 93/$-•-••-----•----- ----------- ----•--•--�------ Date ApplicationApproved By••••-•---••--•--••••--•---••-••••••-•••••••-••-••...--•-•-•••...............................•-- ........................................ Date Application Disapproved for the following reasons:.............................................................................................................. ..---•-----------------------------------•------•-•-------------••---•-•--------------..........----.......----•-..........-•-----•-•------•----••-----------------------..----•••-•••••••••-•-•••-•----- Date PermitNo......................................................... Issued------.....------••••••--••--••-•----------........... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............Z M.................OF........Barns t.able.............................................. Trrtif iratr of Tautplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X ) or Repaired ( ) by.................................................S:teua..Le el,...••....---:-._...--•-•------•----.......----------•-•----........••---------••----••-••••...._...-----•-----••-- Installer ��' /at.......... at- .3 has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUA CE 9# THIS CERTIFICATE SHALL NOT BE CONSTRUE® GUARANTEE THAT THE SYSTEM WI N SATISFACTORY. DATE.......0� . •. --....................................... Inspector....... ..-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T:ot'� .....................OF....Barnstable..... E .. •... No.•••.......••••••••••-•-- FEE........................ Disposal Workv Tuonstradion rrutit Permission is hereby granted..................Steve...Le.be.l..................................................... ..................................... to Construct (l- ) o R air.( an Individ l Sewage Disposal System at No.•••Eat-_d-3 ._ Andy -alley R - Lars ...........................it l s n2ass. ------.-....�r it i. Street q as shown on the application for Disposal Works Construction Permit :�````�.�Da�.:.......•••............... •-----•-•------••-------•----....----•-------•-----------------•-----•--•-...•••••••-••-•.......... DATE. P� 2 Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON N 2-9. /4 '. S2+E 147. 53 or 3 4 loon' , r20 O3�F 1 1� w � t Q 9 Senc �cy0 If low 0 �o. 0 , fl o f' / �fl / N / V. W I (LOT 3 ) CL �OT . . 2) �ie �x ti ZoA,ED k. F. MIN. I;RE/4 ISO' MIIV F)Zon,TAGE 30' MIN F. S. 13 . IS' MIN S&R. L tic A�iSvM pR.0 fb t ?n `• III IBM ps$u M N►CD P/t, . ovAp7e-u R e;, G bare are yI I 10� ~' E LE V. /DO DD / / I e :�' qff. , PHILI W IN Ej y '/ �x dee °%rt SHNDY 1/ALLEV\Fgs/IST OtNrOi:/ �40 }�klligTE �✓qy �NA� LEGEND EXISTING SPOT ELEVATION 0x0 CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 --- r41 FINISHED SPOT ELEVATIONA ;>, � D /y 2.1* 20moY VALLEY /�D !''ARSTOWS 1ltS FINISHED CONTOUR 0 /=:a+'' ROFxERT �ku:i I N APPROVED s BOARD OF HEALTH 1 it . 1 I K, . DATE AGENT �Cqh;'_ ;.�,.�..;;�+ SCALEr I 3c�' DATE 3�r�1-13 �3 LDREDGE ENGINEERING CO. IN P CLIENT. FD_An.r_c_) I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. 8325� BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER URVEY R DR.BYt JDD OF BARNSTABLE # MASS. 712 'MAIN STREET CH. By' &E p'W3 REG. ' LAND SUR VHYANNIS, MASS. :.-� SHEET OF . E EO—R_ �O FT. M/N. /1/OTE /F E/TNER 7-,WC SEPTIC TANK OR lie --,4CN//VG PiT ARE MORE TNA.V 1Z"ffZL0yV ��, /O FT. M/N. _iRAOE� �4 2Q 'O/AMETEK CONCR.ET� COtiER /02.5 SWALL B.F BROUGHT TO GRA oE. GONCRLTE 4 PYC P/Pl /yE,4Vy CAST /RON COVER SH�9LL OE USED M/N. P/TCN �,. coYER.S /B'OF,Q F7 /F/.,V ,DR/V4FWA Y A a �o� Cd ✓ER CLEAN SA NAP 4..CASa� - Z*LAYER . /ICON P/PE v o O o Q F '0 MIN.P/TC/V --�-- G/IL. D/ST• o • • • • . • • • • e ee' OFWASHED 5MYC '/4 Pe�i4 IT. SEPT/C TANK • r • • • • • • • s . • tr BOX n • • B • • • • • � .•• • 34 "'' • • • • pBPri/ • • • • • WASJYfD STONE 40. I&,SX,2.S = Y7 • v PRECAST SEEPAGE fNN�RT ['LENAT/ONd 7�SX/,u - 7� f ►e� • • • o • •.• • o�o P/7 -OR EQU/V. r • : I/VYERT AT 8l1/LO/N6 100.y FT cf G n� jog /NLET ",pn►C T.4NK qg,o fT . L FT. O/.4I+►1. C SEE TA8LIZ 4T/O/V,) OUTLET SEPTIC TANK $B•8 FT. r /INLET D/STR/6//T/ON BOX 177,8 FT. SECT/O/V OF GROUND WArCW Ti�BLE O�lTLETD/STR/BtJT/ON BOX 7•& FT. INLET LArACV.FN4G PIT ge.s FT. SEWAGE OlSIPO�S'A L SY..S•TEM -rAJVLATlON LEACH/!VG P/T DESISM CRITERIA SCALE %" _ !=o' DIM€N.SION A �o FT O/MENS/ON $ FT. NUMBER of aEORooMs 3 o/MENSioN C �`" FT.�� GARQAGED/SPD.MI- UNIT N SOIL LOG TOTAL EJT/MATED FLO14/_330 .G.4L.1DAY SOIL TEST AE/ SO/L 7ES7'#2 .SOIL TEST 11(41148ER QF L,fACNlNG PITS I fFtEY. Z r-ELEY• PATE OF SOIL TEST ZS� r S/OE t1'ACH/NG PER P/T SQ, PT. s 6oTTOM 1FrACN/NG PER P/T 7� $Q, FT. Qom; AAC zz- . 2. GFf0[ 7 �Sv3So�� AevCOLAT/ON /LATE.,*/ -L Z M/IVII/NCH TOTAL LEACH/MG AR,-- A 21-7 SQ. FT. — PEMCOI-A770/V RATE RESER►iEGEAC'N/N6AREA_�SQ. FT. - - s Lor 3y, Svy v��cy >�• r?/ ROBL-RT r" r^ P I S /k BRUCE -+ �o LDREDG ' . , No. 366 �, EL DREDGE E/vGIMMF/NG CO ,I YC. 71Z MAIN ST. , fi/YfINNIS, M.gSJ. �� 1.8�Na GRovN�7 lYNi4TCR ENCOUNTERF� CL/ENT: M GROUND LvATER AT EL EN. _ �rvGO D/9TE� rj /3 83 JOB NO: b'3Z56 SHEET F Z p'r TOWN OF BARNSTABL. F. LOCA11ON SEWAGE # 1 C; VA.LAGE 0 SSESSOR'S MAPIPLO 0 1—L3 INSTALLER'S NAME&PHONE NO. ► SEPTIC TANK CAPACITY /0 60 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS C �� BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r - � i oact -AA 0� A�tS a AcIW OID ��5° COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 71 SANDY VALLEY-RD. MARSTONS MILLS 101'" V'_J11 Q3k-t Name of Owner ED RUSSO +" ' Address of Owner: BOX 266 MARSTONS MILLS f Date of Inspection: 8/18199 ,(f Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Tltle 5(310 CMR 15.000) t« ! A 1 )c.rate Company Name: n/a °y°Mailing Address: n/ay Telephone Number: n/a °'ys�CERTIFICATION STATEMENTI certify that I have personally inspected the sewage disposal system at this address and that the information reported below s�true=a and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Eval at' n By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. (��mit Inspector's Signature: Date:8/18/99The System Inspector shal a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL. revised 9/2191 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99 INSPECTION SUMMARY: Check A, B, C, or D: r A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER nLa revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)1 X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99 FLOW CONDITIONS RESIDENTIAL: Design flow:_W g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):3 Total DESIGN flow: IU Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no):�LQ Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: nLa COM M ERC IAL/INDUSTRIAL Type of establishment: nLa Design flow: nta gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):AQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wa Last date of occupancy: n& OTHER: (Describe) Wa Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: 1998 System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa- gallons Reason for pumping: n& TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: WA APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 13 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 1' Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: E Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ nta Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: L" Distance from top of sludge to bottom of outlet tee or baffle: M 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: Jr How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM EVERY TWO YEAR GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nta Dimensions: n1a Scum thickness: nit 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 nta Date of last pumping: n(a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nta revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) IVA Dimensions: n/a Capacity: n/a gallons Design flow: n(a gallons/day Alarm present: NQ Alarm level:jaLa- Alarm in working order:Yes_No_ NQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n& PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jj& leaching galleries,number: -n& leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: nLa Alternative system: nIA Name of Technology: _nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTU ALL SOUND AND FUNTIONING PROPERLY THE SYSTEM HAD 1'OF WATER IN IT PIT HAS NOT HAD MORE X OF WATER IN CESSPOOLS: _ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. Wa Dimensions of cesspool: nLa Materials of construction: nLa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:Wa Depth of solids: n/A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of t 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8/18/99. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a Deck ro /S o p � C ,o6av � A� ab �� 3a revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SANDY VALLEY RD.MARSTONS MILLS Owner: ED RUSSO Date of Inspection:8118/99 NRCS Report name: n(a Soil Type: n& Typical depth to groundwater: nla USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2198 Page 11 of 11 a(of �; ° C TIO SEWAGE PERMIT NO. e VIL GE "'VIINST�ALLLER'S NA/ME & /-AD0,RESS -� p � 1 O � v� � V� I U I L D E R OR OWNER i DATE PERMIT ISSUED -3 DATE COMPLIANCE ISSUED 3 Y k 39