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Home My WebLink About0167 SANDY VALLEY ROAD - Health 167 Sandy Valley Road Marstons Mills A= 101 103 r Commonwealth of Massachusetts I0I_ /03 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 �M 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name 3> a;• information is _x: required for Marstons Mills iz MA 02648 8-18-18 C; every page. City/Town State Zip Code Date of Inspection t t't 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 4 P.O. BOX 145 Company Address C'EMI-ERMUE MA 02632 City/Town 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 8-18-18 I e s Signatur - 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 M 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 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: ® 1 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 this inspection this system met all passing requirements. The septic tank was opened and the d-box was viewed by camera because it is under the deck. The leach pit was not opened because it was not able to be located by the as-built measurements and it appeared that the pipe exiting the d-box was going in a different direction than the as-built showed. Inspection requirements do not require us to open the leach pit and this one was not because it could not be found. 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. Cityrrown 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): 4 ❑ 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. Citylrown 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 91 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. Cityrrown 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. ❑ ® 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 GSM , 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ® 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. El ® 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 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 s 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: According to the as-built card this system consists of a 1000 gallon septic tank d-box and leach pit. The leach pit was not located. Number of current residents: unknown 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2016-----------307 2017----------—338 gpd Sump pump? ❑ Yes ❑ No currently Last date of occupancy: occupied 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•3113 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 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied 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 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: All components appear 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: 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 moderate heaviest at inlet end of Sludge depth: tank 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 GSM SVO,;� 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. Cityrrown 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 light scum 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.): If tank has not been pumped in the past 3 years I recommend pumping at time of transfer and at least every 3 yrs there after for maintenance. The inside of the tank looked fine at time of inspection with clean concrete above pipe inverts indicating no back ups or surcharge. Grease Trap(locate on site plan): Depth below grade:p g 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 L Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. Citylrown 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 , 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 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.): D box was under the deck so it was viewed by camera and was functioning properly at time of this inspection. 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: We were un able to locate using as-built card (we dug and dug trying to find it with no luck) I also noticed that the pipe exiting the d-box was headed in a different direction than the as-built showed. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 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 was not located due to an in accurate as built card so the exact level of ponding/stainng could not be determined. 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 �_ A Commonwealth of Massachusetts Title 5 Official Inspection, Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. City/Town 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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd Property Address Lancaster Owner Owners Name information is required for Marstons Mills MA 02648 8-18-18 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: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd Property Address Lancaster Owner Owner's Name information is required for Marstons Mills MA 02648 8-18-18 every page. CityrFown 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 B"N"LE LOCATION.0 a c C.�/Jj( J)C(J V 61/ SSE#�✓�SG��T iar1 VILI AGE YYI• M J�5 _.ASSESSOR'S MAP 8c PARCEL R*WOMMS NAME&PHONE NO.-t�,lt-r t r�f(I 'I Yi g SEPTIC TANK CAPACITY 6Q0 LEACHING FACILITY:(type) f1 I(r (size) 1000 NO.OF BEDROOMS OWNER MY'\ PERMrr DATE: SATE ,,t I I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 'lam,'I,,TGIF I IN ,, , `,`,`,`i♦`,`,`i`i iii,`,ii`i ii,`,`,`i i i i,`,`i,`,`, , 2 24 46 29 '� 0 Us�A w � http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=101103&seq=3 8/19/2018 r �nM 1713 02:19p p.1 ■ ■ ■ ■� 4 Commonwealth of Massachusetts Arne Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address James Moran III Owner Owner's Name information is required for every Marston Mill's MA 02648 10-11-13 page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Import nt:When A. General Information ,,,��t�trlrrrr�►,,,, filling out forms "Nr� �INA OF MqOzi�� on the computer, �N _ .- q use only the tab 1. Inspector: �o��: ,�ti key to move your _�: •JAMES tp cursor-do not Sears V l/ 0: James D. use the return o• SEARS — key. Name of Inspector �� CapewideEnterprises LLC. '%�••'cF�TtF��;o��` IG'�f Company Name 153 Commercial St 1/�irrrllnlnttu►��``�� Company Address Mashpee MA 02649 CitylTown State Zip Code 508-477-8877 S1623 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 w 10-14-13 spectoes Signature Date The system inspector shall submit a copy of this inspection report to the Approving Auttority:(Board. of Health or DEP)within 30 days of completing this inspection. If the systemis a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system over shall bmib re report to the appropriate regional office of the DEP.The original should be sent to the&sterxlowner and copies sent to the buyer, if applicable, and the approving authority_ trt r" ""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. to`�Vfs t5ins•3i13 Title 5 0[Tidal In Farm Subs aface Sewage Disposal System•Page 1 or 17 Oct 1713 02:20p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address James Moran III Owner Owner's Name information is required for every Marston Mill's MA 02648 10-11-13 page. Cityfrown 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: 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): t5irre•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Oct 1713 02:20p p.3 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran III Owner Owners Blame information is required for every Marston Mill's MA 02648 10-11-13 page CiVrown State Zip Code Date of Inspection B. Certification (corn.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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•3113 Title 5 official Inspection Form:Subsurface Sewage Dispose)System•Page 3 of 17 Oct 1713 02:20p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran Ill Owner owner's Name ation is requrired for every Marston Mill's MA 02648 10-11-13 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 DER certified laboratory,for fecal col'fform 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 wmEpwK is less than 6°below invert or available volume is less than'/day flow Piz^ 15im.3113 Title 6 OfFdel inspection Form-Subsuftee Sewage Disposal System•Page 4 or 9T Oct 1713 02:20p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address James Moran III Owner Owner's Name information is required for every Marston Mills MA 02648 10-11-13 page_ CitylTown State Zip Code Date of Inspection B. Certification (cunt.) 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. 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 11 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. Wins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Oct 1713 02'21 p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran III Owner Owner's Name information is Marston Miles MA 02648 10-11-13 required for every page Cityfrown 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 ❑ 0 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El 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 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 (Sins•3113 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Oct 1713 02:21 p p.7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran III Owner Owner's Name information rlevery Marston Mill's MA 02648 10-11=13 page. CitylTown State Zip Code Date of inspection D. System Information Description: The system is a 1000 Gal tank,D Box and pit 2 Number of current residents: 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 Z No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2011-35,000Gals g ( y g (gRd}}- 2013-33,000Gal's Detail: Sump pump? ❑ Yes E No Last date of occupancy: Present 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/personslsq,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 Of rial Inspection Form:subsurface Sewage Disposal System•Page 7 of 17 Oct 1713 02:21 p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address James Moran III Owner Owner's Name information is required for every Marston Mill's MA 02646 10-11-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: 6-7-13 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•W13 TRIe 5 Of6del Inspection Fomt Subsurface Sewage Disposal System•Page 8 of 17 Oct 1713 02,22p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form a I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd - Property Address James Moran Ili Owner Owners Name information required for every Marston Mill's MA 02648 10-11-13 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 30" 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.). Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): 19" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: yew Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast 1" Sludge depth: t5ins•3f 13 Tide 5 Otti W Inspection Form:Subsurface Sewage oisposal System-Page 9 of 17 Oct 1713 02:22p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address James Moran III Owner Owner's Name information is MA 02648 10-11-13 required for every Marston Mill s page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank (cont) Distance from top of sludge to bottom of outlet tee or baffle 29" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" 16„ Distance from bottom of scum to bottom of outlet tee or baffle Asbuilt-Tape How were dimensions determined? _Sludge.fudge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank and cover's at 19' below grade. Inlet tee,outlet baffle. No sign of leakage or over loading 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-3113 Title s osciar inspedion Form-subsurface Sewsae illsoosaf System Page 10 of 17 Oct 17 13 02:22p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address .lames Moran III Owner Owners Name information is required for every Marston Mill's MA 02648 10-11-13 page. Cityfrown 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 t5irvs 3113 Title 5 O]fir ial Inspectim Form:Subsurface Sewage Dispose]System•Page 11 of 17 Oct 1713 02;23p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran III Owner Owner's Name information is Marston Mill's MA 02648 10-11-13 required for every page. Cityfrown 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.): Did not open D Box, D Box is under deck. Locate and camera D Box. Box looks ok. No sign of over loading. 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-3M 3 Title 6 Offtdal Inepecbon Form:SubsuAaoe Sewage DWposal System-Page 12 of 17 Oct 1713 02:23p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran III Owner Owners Name information is Marston Mills MA 02646 10-11-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: z leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemabve system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is a 1000 Gal. Precast Pit. Pit and cover at 29"below grade_ T water in pit No sign of over loading or solid cant'over._ No high stain line,wall's are clean. 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-U13 Tile 5 Official tnepection Form:Subsurface Sewage Disposal System•Page 13 of 17 Oct 1713 02;23p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address James Moran III Owner Owner's Name information required for every Marston Miles MA 02648 10-11-13 page. Cilyrrown 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 Tale 5 Offidel Inspection Form:Subsurface Sewage Oisposal System•Page 14 of 17 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) m A 7L pATA Oct 1713 02:24p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd. Property Address James Moran III Owner Owner's Name information is required for every Marston Mills MA 02648 10-11-13 page. CsylTown 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 / a/ / / / I • Ilra aJ a/a/ /a i a / `Ia%% ` ` `I i r`r/a%I i `%%/Ia%%%i Ia/ai/a%%%i/`%i/ar♦/�%/ a♦ a a\\ a \ \ ♦\ ♦a \ \ • \ \ a \ \ \ a a \♦ \ ♦ \ \ ♦ \ \r\/a/\/♦I♦/� \\ram\\�J\♦/�\\1\!l\\ \/a/\\ \ I f / I / I / f I I I / / , J / I I / , I I \ a♦ \ a \ a a♦ a\ a a a \ a a \ a l \ \ a\a \ \ \ a \\ a \/`i Ia%faf`/ara ai Ji`/`/ f`J\Jai r i/♦/ai i ai iai.a :a/`r • a \ a \ ♦ a ♦a \fad\a a a \ a l ♦a a a \ a a \ a�\ \ \tea ♦ \ 2 2d all , 46 29 f - Oct 1713 02:24p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran III Owner owner's Name information is required for every Marston Mill's MA 02648 10-11-13 me City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na Estimated depth to high ground water: eet r 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 160 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: G W 20+' Below grade per past report Bottom of pit at 8'-6" below grade. Before tiling this Inspection_Report,please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Offidd Inspection Form:Subst0sce Sewage Disposal System-Page 16 of 17 Oct 171'3 02:24p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 167 Sandy Valley Rd Property Address James Moran III Owner Owner's Name information is Marston Mill's MA 02648 10-11-13 required for every page. Cityrro`n+n 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•3113 TKIe 5 Mitt!Inspection Fond Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARN ABLE LOCATION `= X ! (d( 4 E#�'t�St�°Ce7,i0✓) •C owl � � � .� VILLAGE SESSOR'S MAP&PARCEL 1NWMMmPWS &PHONE NO. Gkl'kfidr� r,O I 1 1- nnet q g SEPTIC TANK CAPACITY 6CX) Lor LEACHING FACILITY:(type) 21,(r (size) JOCK) NO.OF BEDROOMS OWNER C)fXkV \ PERMIT DATE: ATE ✓► 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 • �\V S 4f\ \r\/\f\rlf\ \J\r \f f \r f\f\f\f\/\f\r '4 � , 2 24 46 29 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is Marstons Mills required for MA 02648 June 7, 2011 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Imports"`:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name �� 189 Cammett Road Company Address Marstons Mills MA 02648 team Cityrrown State Zip Code 508-428-1779 S1 12855 Telephone Number License Number ,-B. Certification tf 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection c-was performed based on my training and experience in the proper function and maintenance of on site c *� sews e disosal systems. I am a DEP a� 9 k p Y pproved system inspector pursuant to Section 15.340 of Title 5 (31b CMR 15.000). The system: ® lasses ❑ Conditionally Passes ❑ Fails ❑ Deeds Further Evaluation by the Local Approving Authority "—ectorrs June 7, 2011 Job# 11-97 re 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. 11-97 Moran 167 Sandy Va.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching pit showed no signs of surcharge. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 11-97 Moran 167 Sandy Va.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 \, Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 11-97 Moran 167 Sandy Va.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 _ every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". I Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 11-97 Moran 167 Sandy Va.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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. 11-97 Moran 167 Sandy Va.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City[Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] 11-97 Moran 167 Sandy Va.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 32,000 gal. _ 9 ( Y 9 (gpd)): 44 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. 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: Last date of occupancy/use: Date Other(describe): 11-97 Moran 167 Sandy Va doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 2003 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 6/24/84 Were sewage odors detected when arriving at the site? ❑ Yes ® No 11-97 Moran 167 Sandy Va.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' 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): 1' Depth below grade: 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: V. Distance from top of sludge to bottom of outlet tee or baffle 29,E Scum thickness Trace Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Measured 11-97 Moran 167 Sandy Va.doc•08t06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road _ Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in need of pumping at this time, liquid level was found at bottom of outlet invert. Tees are intact and clear. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 11-97 Moran 167 Sandy Va.doc•08I06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 167 Sandy Valley Road _ Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): 11 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 11-97 Moran 1E7 Sandy Va.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A,.•''� 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 _. every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Leaching pit showed no signs of surcharge or hydraulic failure 11-97 Moran 167 Sandy Va.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 11.97 Moran 167 Sandy Va.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 167 Sandy Valley Road Property Address James Moran Owner Owner s sJame ti is reequirequired to( Marstons Mills MA 02648 June 7, 2011 _ every page city/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Sandy Valley Road Water Service Wage,g \i . • tr 2 24 . 46 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM a,.•'` 167 Sandy Valley Road Property Address James Moran Owner Owner's Name information is required for Marstons Mills MA 02648 June 7, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 40 and topo map shows property at el. 70. i 11-97 Moran 167 Sandy Va.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BAAR�NSTABLE ', OCATION iU 1 7 5 y/. ycd(w/ Y-CX SEWAGE# ji'ti5D VILLAGE rn dYl�)'I�.S ASSESSOR'S MAP&PARCEL !-S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) Yid (size) /000 NO. OF BEDROOMS OWNER c.c_ MAUL PERMIT DATE: DATE: P i'� oe) 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 F r ? 1 f F F F r f f r r r f f f F f r f f f f ! \ \ \ t.♦ ♦ \ \ \ t \ t ♦ \ \ \ t t+t t t t \F f f+atot.lt t{tFtftJtJt i fti t! / !~f LrtftftFtf � ♦ \ \ \ t t \ \ ♦ \ \ \ t t h h \ h \ t t h h h \ \ \ - ♦ \ \ \ \ t h ♦ h \ \ h h h h h h \ \ \ \ \ \ \ h h h t \ t \ \ \ ♦ ♦ ♦ ♦ ♦ ♦ ♦ \ ♦ \ \ t \ \ l t h t h \ \ t't h t t t t t t t \ ♦ \ \ t \ \ t t t \ \ t t \ t h ♦ \ \ t ♦ t h ♦ h t t \ \ \ t t t t 2 24 46 29 J ` TOWN OF BARNSTABLE LO,CATION I Cv� SG►mot✓ y&I l,�/ I�Q #�' 4VILLAGE IM• IS ASSESSOR'S MAP & LOT UaWffiffWS NAME&PHONE NO. 't` 'L'C-OR-40 Y► ,11 �'/o ^I?'79 SEPTIC TANK CAPACITY LEACHING FACILITY:.(type)'�—?f (size) NO. OF BEDROOMS I BUILDER OR0WREt> Line r�rr p�'f�`So v� PERMITDATE: C@b4VE2aNCE DATE: It3 OHO 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 r_ within 300 feet of leaching facility) Feet Furnished by Sandy Valley Road ater Service a E 1 ..... ...... 2 i 24 igg i r 46 29 1- 103 *63- 91?Y WV �I C,q T ION E W A,G E PERMIT NO. 7- `/o �a9 e 1 �,,,VwI-LLAGE ` )�,, cj,INSTA LLER'S NAMj ADDRESS _ ® U I L D E R OR OWNER 14 e C;) //1" DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� l _ ufict< L Iz 3� � O Y6 y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH To�,m Barnstable ...--- ............. ....................OF......................................... ........................ Appliration for Uhiposal Works Tontrurtion Prrutit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: U / ) &I ,ot rt 4�0, Sandy Valley Rd. pMarstons Nlills ' IrA t�SE` ........:....•---.................-•-•-•:----.....................-•-••-•--.........._. ..........•••----•-•---•.._........•-•----------- ------.y----- --------- Capricorn Reae�`fy 'ru` st 765 Falmouth Roast N annis ......................_.......................................................................... .--••..........-•--••-•-•••••-•-••.........-----............-••-•••---•......----••••----........ W Steve L e b eel owner Address a ._.........-•--••-•••-.....••-----•......................................••••--•......-••-........ ..........--••-•---............-----•-•-•••--••-••••-••••••••....................----•-••--....... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_3........................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building z @Jlgb............... No. of persons............................ Showers (2 ) — Cafeteria ( ) Pa Other fixtures .------••--------•-•--•-•--••-••---••-•--•.............. Design Flow.......5.5...............................gallons per person per day. Total daily flow.......33.Q........................._..gallons. W 000 O'6.. 1 l �� '8'1 W ' Septic Tank—Liquid capacity�._..._..:..gallons Lengt ................ Wid& ..lil� 801 Diameter__._..__.._...__ Depth_-•-_--••-..._. x Disposal Trench—No. .................... WidtJi�................._ Total Length.................... Total leaching area.._2��____....sq. ft. Seepage Pit Nal................... Diameter._._.bb._._...._.__._. Depth below inlet..._................ Total leaching area............__._..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) H .............. Engineer*.............. ...........> ............... .............. Date....._.._......... ...._................ 0- Test Pit No. 12..0_._._..minutes per inch Depth of Test Pit.1L.!........... Depth to ground wate�One...enCO.unte - Gi. Test Pit No. ..A.......... per inch Depth of Test PAVA............. Depth to ground water!VA............... e -- ---•• .... --...... Description of Soil._...._.�_�____- 2 loam_-& topsoil•_•-.-_.__•-. _-••- .......-. ------------------------------------•--. x 2' - 10' D'ledium yellow sand 10' - 12' med. white sand traces of ravel no water at 12 ' W . . .... -••................•-----••-. •-•-----••-•......--•--------• -•---•---._.........•••......__........-•-----•-•----. •--...-•--- .. .. ...................................... Nature of Repairs or Alterations—Answer when.applicable................................................................................................ ---- --••-•--•-••-•••••••-•••---•--•••-•-•-••••-•-••-••----••-••••-•••--••-•--••••-••••--••••..................•-••-----••-....-•••----•••-•-•-••••-•- Agreement: The undersigned agrees to in tall the aforedescribed Individual Sewage Disposal System in accordance with the provisions.of ilTIE 5;of the ' tate anitary Code—The undersigned further agrees not to place the system in operation unt. a Certificat`of C pli c as een�issued b the boar health. t ._......_Pres.. 4 _22 ... ...... Application Approved BY.......... ....... ............................................................................ of 3 Date Application Disapproved for he lowing reasons:............................................................................................................... - ..............................•-•.....•••---....._...••-••••..._..--•----•........•-•--•---.....................--•-----••--•-----..........••-••••••-•••----••....••••-•---------.•-•-••••--•--••---•--- Date PermitNo......................................................... Issued-.................. ............................... Dattee 4 No................ l Fmc.......y� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Toym Barnstable ......... ......... . ..................OF...................................... Appliratiun for Di,ipsal Vurkg Tonstrurtion Vamit Application is.hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System. at: Lot #40, Sandy Valley Rd. ,Ylarstons Mills , RIA .........................•----•-•--••-•-•----......................-•-••-•-•-•••.......--•.•--••.. . .................................................................................................. Capricorn R&Wjt2 'dtrUSt 765 Falmouth Rd`a-d NO-Hyannis ......................_.......................................................................... -•---•--•-----------••-----.....-----........_.......-••••••---•---•-••........................--- w Steve Lebel Owner Address Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms ra-3Ch. ..._..Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) Q' Othg5fixtures .....••-•-•----•----•-•--••---•-----------••----•----.•---•--•---•••--••••-•--•-••••-•----•--•---•---.-----�-------------•-•------................. d w Design Flow...............................1ddd..gallons per pers ge>; day. Totgl �liily.flow--- 33 gallons. WSeptic Tank—Liquid capacity..........:.gallons Lengtl ............. WidtH................ Diameter................ Depto.............. x Disposal Trench—No..................... Widt .°------------------ Total Length_..... .r--------- Total leaching area....._. . . sq, ft. Seepage Pit No------------- ________ Diameter.................... Depth below inlet................. Total leaching area..26�......_sq. ft. Z Other Distribution box ( ) Dosin a k 14 �rSdde Engineering 11-25-81 Percolation Test Res ]ts Performed by......................................... r Date........................................ ------•••--•-- a 0 1 one encounte - 0-4 Test Pit No. }�_.�.___..._.mmutes per inch Depth of Test Pith._A._.......__. Depth to ground wate>n::.. ................. Gi, Test Pit No. 2:.........._minutes per inch Depth of Test Pi-'. ............... Depth to ground water.r.J'�............___. e O Description of Soil....__.... -r----- ,------ ,oam--&`•---•ops oil.................................----.......-----..........-.-.......--••-•-----•----•-•-- 2 =-- D T�ledrum - x yellow sand 10. _ 12T ined;...IR to-•-sand/tracQs._o '..gravelJno. water...at---12 -------------- ---------------------•-------...------------------•--------------------------------------•--------------------------------------------------------------•-------.....------••-••-••...... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...................................................•----•--•---.._....--------------........-------•--...---...------.---------------------------------------------•--••-•-------•----•-----•-.....---• Agreement: The undersigned agrees to i stall the aforedescribed Individual Sewage Disposal System in accordance with the provision of ITLE of th State. anitary Code— The undersigned further agrees not to place the system in operation un 1 a Certificat of mpli ce has been issued by the board of health. -;gn Ire s 9� 2� ................ fJ ---- ..�...... ApplicationApproved By..................-= ------•-•--••--------•••-----•-•---------•.....................•---•-----. Date Application Disapproved for e f owing reasons:------•--------------------••-------------------------••------•---------•-•-•---•--......_...._--------•-----•- --------------------•-•--...........-----••--•--••-----------•--••-•------------••-----------...---•----........-------------------•-------•-•---••-------------....------------••-•------•-..._......... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T oiyn Barns tabl e ............................................... ...............................O F...................................... (Inrtif iratk of Toutpliatta THIS IS TO CERTIFY TThat the Individual Sewage Disposal System constructed (X ) or Repaired ( ) Steve Le�el by----------•------------------------- ------------..._.-----------------------------------------.---------.---.--------------------.---.--.-...-------.--•--.-----------------•--•---- Lot A0 , Sandy (alley Rd. I Install Marstons Mills , IiA at......... ............•------------•-••--.......------•-------•--•--•-••------.........--••---•----•-••-----------•--•------.....••--•-------........................... ........ =.._..._ has been installed in accordance with the provisions of TI ,j o� 'f State Sanitary Coy_ie escr• din the application for Disposal Works Construction Permit No_!..................................... dated---------- _.___ .... ___..._................. THE ISSUANCE F THIS CERTIFICATE SHALL NOT YCONSTU AS A GUARA EE THAT THE SYSTEM—YiI ZFU T ON SATISFACTORY./DATE......... ... ............ ... ..---------- Inspec ----•-._......---•------------------•-... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T owri 'arns t abl e ...........................................OF.....-............................................................................... �J � No........................ FEE........................ Riipoual lVarkiiion trttrtion rrmit `Move rebel PermissionIs hereby granted------------------- ----------------------•-------..........--------------...----•--•---•-----------.......---.............................. to Construct,_�: )lob Reprn(� ).,a�lI �v dtll Sew Di osal System 1'o1 °..... y.. .......-'-... arsrons Mills , i,1A at No...-- ......---•---- . ....---••----- . • . •-•..............•-•---•-... •..•--• _ Street 11 as shown on the application for Disposal Works Construction Per - �1 �� ' !'� --- ---�-----__ Dated-------------------------•-----•--....--- ' ••--------••••--•. ........ ------•-•-----•••--------••--•-•-•--•....................••----•-•-------- Board of Health DATE.......... .�--• -_///.................................... `�. FORM 1255 A. M. SULKIN, INC., BOSTON x, "3 L oT- 4-o PIT 20� 00 r - M �V .I .i I s .. o NU TE.' 4.11 � o I /2'eFp/z 1>4 \- v� O r� �. � o A.d Ui o ORSE G'ST& 3 v/�s'/�r Fs�TONAL E��\ LEGEND CERTIFIED PLOT PLAN r: EXISTING SPOT ELEVATION Ox0 '�'� '• � � EXISTING CONTOUR ——— 0 ---- �c 4r �.UT Y b S'/9��y VALLE% 7Z/> �iG •.-RT 'ir- FINISHED SPOT ELEVATION :. FINISHED CONTOUR 0 `f. TRUCE M �{ ILLS- / t APPROVED , BOARD OF HEALTH vI �°mot 1 DATE AGENT J '' ' " SCALES "f 310 DATES (LDREDGE ENGINEERING CO. IN CLIENTc I CERTIFY THAT THE PROPOSED EGISTERE REGISTL,RED JOB NO. 9-3 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER -,SURVEY IDR.BY' '^ ' OF BARNSTABLE, MASS. 712 MAIN STREET . CH. BY, HYaNNIs, MASS. SHEET � � � = . .�.----_.��-1._ SHEET— OF DATE REG. LAND SURVEYOR 24 t7 MI/Y. .`l07E /F /TNGR :NL�S�PT/C TA,V.4C OR • '_E�1CJH/ivG P/T A.tE MORE TNq:•� /2"8EL01"v %O M/N. 4't'YC P/PC SNALL BE 41-Z0 GHT TO GRAOF • CONCRITL i /4 E.4 V y. CA S T /,P o V C MI_N. 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