HomeMy WebLinkAbout0015 SCARLET LANE - Health sky::li 15 SCARLET
a
` TOWN OF BARNSTABLE
LOCATION 5 ,i�z/f., iZe SEWAGE#
VILLAGE A'[E LC PASSES SOR'S MAP&PARCEL
INSTALLER'S NAME.&PHONE NO. �,G•1 ���l� f--6I-3��
SEPTIC TANK CAPACITY 1=7KI M(K S4, 1000
LEACHING FACILITY:(type) (size) �DC U•TS3
NO.OF BEDROOMS
OWNER—
PERMIT DATE: COMPLIANCE DATE: 12 &
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility - —S Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) N Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) IA— Feet
FURNISHED BY
!/� O G -a 30 , ,,'
Commonwealth of Massachusetts
Title 5 Official Inspection Form 171"1
ASubsurface Sewage Disposal System Form - Not for Voluntary Assessments
/- P y�
SCGrle, 4G k1e-
h
Property Address n
Owner Owner's Name %�� l / /� l Y/�
information is ' S � " � / �� �
required for every —
page. City/Town State Zip Code Date of Inspec n•.,)
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector I f ration �� �3s0-I-,filling out forms
on the computer,
use only the tab
key to move your Name of Inspector
cursor-do not Eiflkll O
use the return Company Name
key. / /
�O CT
Company Address / 1 / 4 od- 7/TI
��J A
City/Town 1 �n� —/��,(�� State ' ��� Zip Code
Telephone tumber License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); i have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection l have determined
that the syst .
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
?iJe 5 `dal'inspeccon=om:sut'surace Sewage 0:pcsai system•Page of 18
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Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
C11 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
IS sCa tr
Property Address:
De-IltA C,:�
Owner Owner's Name /f� ( Q�
information ishe
required for every AJ61✓S1�v1,S AM/S 1//4 O0l6 � �O2
page. Cityrrown State Zip Code Date of In pection
C. Inspection Summary
Inspectior Summary: Complete 1, 2: 3, or 5 and all of 4 and 6.
1) ;Uot
ses:
found any information which indicates that any of the failure criteria described
in 31 C CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass' section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes', "no" or"not determined" (Y, N, ND)for the following statements. if"not
determined,' please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Title 5 pt5oai mspe tdc :orm suosurace Sewage Jisposa system•?aye 2 of 18
t5insp:ooc•rev.72612018
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�s _!�Ca r le
Property Address
De,/uey
Owner Owner's Name
information is 13es-414f 4S 0j6V$
required for every
page. City(Town State Zip Code Date of Aspecti6n
C. Inspection Summary (coot.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
-itle 5 OYdai -.specnon Fonn:Subsurface Sewage=isposal system•Page 3 of t8
t5insp.doc•rev.71262015
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.—ScaPrl4e,7L/1
Property Address
OPU C
Owner Owner's Name l q
information is 141
required for every �yYS.kNf �// //�� ~�d �tfo �/ �°211,g
page. City(fown State Zip Code Date ofA specti
C. Inspection Summary (cost.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply..
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*'`.
Method used to determine distance:
**This system passes if the well water analysis; performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
Z 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
Tiye 5 QiSaal!ns?enon Form:Suosurface Sewage oispcsal system•Page 4 of 18
t5insp.doc-rev.7262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
e UC
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of/specticfn
C. Inspection Summary (cost.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
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 '/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or
u 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.
El Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
(] ny 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.]
e system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes23 or"no7�to each of the following, in addition to the
questions in Section C.4.
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
El Area—IW PA) or a mapped Zone I l of a public water supply well
?itle 5;;tfdai Inspection corm:Subsurface Sewage Disoosal System•Page 5 of 78
t5irtsp.doc•rev.7262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form Not for Voluntary Assessments
,17
Property Address
ACC
Owner Owners Name NS �/" /( o b
information is �`�•
required for every State Zip Code Date o nspe on
page City/Town
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
Yes
❑ P ping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ e 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)
[v]/ 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)]
7;Ue 5 CfSdai in �.i speon Forn:subsurface sewage Disposal system•?age 8 of 18
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t
Commonwealth of Massachusetts
if Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name I
information is G rs7+��s �� �, 62d G q$ 4ofup�ectiofirequired for every State Zip Code Da
page. CitylTown
D. System Information
.1. Residential Flow Conditions:
Number of bedrooms (design): dumber of bedrooms (actual): ^30
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): s
Description: / /600 �
Number of current residents:
Does residence have a garbage grinder?
❑ Yes lot
Does residence have a water treatment unit? ❑
Yes o
If yes, discharges to:
Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ��10
information in this report.)
❑ Yes No
Laundry system inspected?
❑ Yes [ENO
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
❑ Yes No
Sump pump? C w6Le!! '
Last date of occupancy: Date
-ioe 5 C-fiaai nspecdon Fcr.Sudsu`ace Sewage Disposal system.?age 7 of 18
c5insp.doo•rev.712V2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
CGrle7T
Property Address
Owner Owners NamAla"j4wf
information isA- 4required for every b"rU
page. City/Town State Zip Code Date df Inspedon
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.).-
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as par of the inspection? ❑ Yes
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc rev.7r2612018 -itie 5 ofiaal inspectior.=orm.Subsurface Sewage Disposai system•?age 8 of 18
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /�C
Owner Owners Name I ,/� D� /a Q
information is y f Z O o _
required for every A�l
page. City(Town State Zip Code Date e inspitction
D. System Information (cont.)
4. Type
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):
Approxi to age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site?
❑ Yes ' No
5. Building Sewer(locate on site plan): C;11S,
Depth below grade: feet
Material of construction:
❑cast iron 4 0 PPVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
-;t;a 5 `dal inspection Fom.suosur7ace sewage-Disposal System•Page 9 of to
t5insp.doc•rev.7/2 6120 1 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -/Not for Voluntary Assessments
Property Address
C�
Owner Owners Name
information is /��
required for every G=rS Ohl
AV
page. City/Town State Zip Code Date f inspection
D. System information (cons:)
6. Septic Tank(locate on site plan):
Depth below grade: feet
M en 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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined? Lok
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
�✓I OG �ONG/��✓! .
-tile 5 otoal Inspection Form.SLDSIJRace Sewage Disposal System•?age 10 of 18
t5insp.doc•w.7/2 61201 8
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' ,1, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is � Oa6 f H /9'
required for every
page. C4/Town State Zip Code Date of specton
D. System Information (cost.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
I
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
?itle 5 ottnia'.irPecuor,Form:Suosu3ace Sewage Disposal system•Page 11 of 18
t5insp.doc•rev.7/26iNi8
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1
�S .L—/l/
CC; ��
Property Address
Owner Owners Name
information is ` arrARs 00)
required for every
page. C4/rovm State Zip Code Date ofinspetition
D. System Information (cons.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box (if present must be opened) (locate on site plan): wP
Depth of liquid level above outlet invert
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.):
� Sal�f
T;tle 5 o4oai:nsoecjon=or,suosurtace Sewage Disposal System•?age 12 of 78
t5insp.tloc•rev.71`26=18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owners Name /)` /(�x
0�
information s /// C.r4v NS �/S t0 O
required for every
State Zip Code Date.of In pection
page. City/Town
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan. excavation not required):
if SAS not located, explain why:
Type: 0
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
overflow cesspool number:
❑ innovativeiaitemative system
Type/name of technology:
one 5 oar:nspe.Tjon For,SUDS�T!^e Sewage uisposai System•page 13 of 18
:Sinsp.doc•rev.726/2018
N Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name1111a
information is rs.T`�yf ��/
required for every
page. City town State Zip Code Date of l ypcton
D. System Information (cons.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc_):
01
12. 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.):
give 5�cal Ispemo,:ort.s"su}ace Sewage D�sposai system•?age 14 0!t8
t5insp.doc•rev.7262018
Commonwealth of Massachusetts
p Title. 5 Official Inspection Form
�i
N. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
1�e lu cC--
Owner Owner's Name /
information is a�rs�v✓!f l� Oy�f+�(C/ '
required for every ��""
page. City/Town state Zip Code Date of I spection
D. System Information (cont.)
13. 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.):
Tine 5 ot5aat;nspecoon Form,Suosudace Sewage a5posai System•?age 15 of 18
t:insp.doc•,ev.71262018
T
r
Commonwealth of Massachusetts
z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.� scar/Pi z�
Property Address
Owner Owner's Name
information isGi/Y�pr1S
required for every
page. City(Town State Zip Code Date of 6spedon
D. System Information (cons.)
14. Sketch Of Sewa Disposal System:
Provide a vies f the sewage disposal system, including ties to at least two permanent reference
landmarks !benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the buil ' g. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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Title 5-float inspection Form:SubsLr ace Sewage Disposal System•Page 16 of 18
t5insp.doc-rev.712612018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
e Au
Owner Owner's Name
information is ors 0 t //g // 1�
required for every 7`e d-b r L'I
page. City/Town State lip Code Date of(nspedtion
D. System Information (cost.)
15. Site Exam:
❑ Check Sope
❑ Surface water
❑ Check cellar
❑ Shallow wells ! 0
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
erved site (abutting property/observation hole within 150 feet of SAS)
Checked with local Boarf Health - explain:
avLS f �_EO 4l�f
Checked with locai excavators; installers - (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
G of �I/ e
[PIS 7�- 1e2 P144
4, 14do��257_
t V I u✓ICGt/d�(/
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
5insp.doc•rev.72EW 8 -ise 5 5aai inspe=orl=cr:Subsurface Sewage Disposal System•Page 17 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
e �u cam,
Owner Owners Name
information is aY� aS '
required for every
/c
page. City/Town State Zip Code Date of fnspectibn
E. Report Completeness Checklist
Complete applicable sections of this form inclusive of:
A. 1 pector Information: Complete all fields in this section.
B. Certification: Signed 8t Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, cy5 completed as appropriate
4 ilure Criteria)and 6 (Checklist)completed
D. System Information.-
For 8:T ght/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Title 5 ol5aai:nspecmon a SuosuCace sewage oEsposat system•?age 18 of 18
t5insp.doc•rev.7128i2018
y No.�.o`��� [ V
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpliLation for Mispo8al *pstrm Construction permit
Application for a Permit to Construct( ) Repair 0(f Upgrade( ) Abandon( ) ❑Complete System Ondividual Components
Location Address or Lot No. IS^Scar jet Cm , Owner's Name,Address,and Tel.No. SUg—34G 01 ,j CQ a3
Gti{arsl-vti�s Mi l IS Po, L3ox �6/
Assessor's Map/Parcel/�fS f(oa Thn oa(
Installer's Name,Address,and Tel.No. 5b$-77/- 9:?"g 9 Designer's Name,Address,and Tel.No.
�ordo lcsf C�vnsk�e��iss =n c �s'—L,x@ �Ovt ua
Type of Building:Dwelling No.of Bedrooms 3 Lot Size 41G 9?a sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures (`
Design Flow(min.required) �J�j(� gpd Design flow provided 30 gpd
�
Plan Date ,'Zo O�(� Number of sheets / Revision Date
Title �. J �� S MA
Size of Septic Tank e: jX s�,ylg, /DopgoS Type of S.A.S. - Mos2z,vO
Description of Soil2 jI29
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code�. o place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. '�
Signed Date
Application Approved by 0 Date /6
Application Disapproved by Date
for the following reasons
Permit No. 0- l V Date Issued t6 31- f�o
Fee f U V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION = TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpYication for Misposal 6pstetn Construction Permit
Application for a Permit to Construct( ) Repair 0 Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. �� C' Owner's Name,Address,and Tel.No. So 8f 36 ;) `/6 P3
Assessor's Map/Parcel Jyg&( a ULIa rst���5 iu r(IS hr, -L�- Po' i�t,, QP
Installer's Name,Address,and Tel.No. 50$-0")/- `)3`)9 Designer's Name,Address,and Tel.No. _DE E- y5y/
( ,r ,IvtEt C'c,n5�ccz1 � icy anc - 4 C et-3 dt/at41 s
' ( Ro 1!VE a I rD2 o O
Type of Building: v
Dwelling No.of Bedrooms 3 Lot Size �3 9�/oZ sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33U gpd Design flow provided 30 gpd
Plan Datejpc+v6-„ ,),,3tGi L- Number of sheets / Revision Date
Titl 5 i m I I k, i M A /
Size of Septic Tank P_.0 r'C�iS /OOOSa Type of S.A.S. �r,6
✓ /a,5 X�S
Description of Soil,!2 -c_e
S
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code•and-not o place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. ,
Signed Date
Application Approved by /` Date /6'
Application Disapproved by r' Date
for the following reasons
Permit No. 616^ M, Date Issued /6
----------------------------------------------------------------------------------------------------- ---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Q� Upgraded( )
Abandoned O by 1 C t j O C
at lAr /5 k r6 has been constructed in accordance
wiP the provisions fof Title 5 and the for Disposal System Construction Permit No.0?016 U dated
Installer ��jpr�- " � e�✓i.�f/�� r�C Designer um jr,,7Q F .eiy7conrnw5 , — C
,l
#bedrooms Approved design flow nr J i V gpd
The issuance of this pe t shall not be construed as a guarantee that the system will ,nctio adesigned.
Date 1��� b Inspector
-------- --------------------------------- -----------------------------------------------------------------!(J tJ
No. r�01 r3 3 ! O Fee (/
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
30isposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(,K Upgrade( ) Abandon( )
System located at j, ��41e f'J� M/15 /2
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. J--�
Date _ 3(" I f Approved by
dV7
Town of Barnstable
WE Regulatory Services
o
Thomas F. Geiler,Director
ente
MAS& Public health Division
i6gg. 10
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: �°� G �6 Sewage Permit# 6Wi_3 D Assessor's Map\Parcel /V/ N
CryDesigner: ��� GL 2 rrlEc.h Installer: Or i10
Address: it Address: �' �' �V Y- 70
On `G-31-16 T� a ,� rt5�/' �n�was issued a permit to install a
(date) (installer)
k
septic system at / s �� �(Ive based on a design drawn by
(address)
( p
dated
/ ( igner)
►� I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic flank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic sy ) but in accordance with State &Local Regulations. Plan revision or
certified as Alt designer to follow.
��tN OF
DANIELA.
(Installer's Signature) U nJALA
CIVIL
No.
C9� .P Q
, ,//(Q SSIONAL eNG
(Designer's Signature) (Affix Desi er's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
Town of Barnstable P#
_ BO,r�y��"-
e! t�mentFof Health'-Safety� ,andTEnvtronmen,tkl Services,
AIM P-ublic H,r6m h Di'Aim'di Date.
367 Main`Street,Hyainis MX0260l'
9 a.+a+xarserE, � �yyt
Mites. 7f'
0r�ti tA Date Scheduled U Time ► Fee Pd. "IN
r
Soil Suitability Assess M`ent,for &wae a Disposal
-�Performed By: ��� ` ��� t Witnessed B�:. v. �+ Qp
..................................:•.:�::.�:•::::•::::::::::::::.::.;:::.;•:.;::.....;•:::::..;:•.;:..;•.::»>::::»>:z:>::::r,:>::::s:<::<::<:::::»i:<:>:<:::: : ::»:<>:
Location Address /`sC4_, � �/� Owner's Name J CC,0_
M.
Assessor's Map/Parcel: Tu Bngpneer's"Name 0 t,vv� �Q
NEW CONSTRUCTION REPAIR Telephone# 6EoeL36da — "rf
Land Use �A 0e Slopes(%) Surface Stones
Distances from: Open Water Body `eft Possible Wee Area 110&0ft Drinking Water Well
Drainage Way yt d ft Property Line Z j ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
�
rt� _
I�
f 61
i'�.. . .. .Ee"V . . is• ` �: a
Z70118 l
Parent material(geologic) (4'C�G l t t Depth.to Bedrock Z�G
/'
1 Y
Depth to Groundwater: Standing Water in Hole: & )t� Weeping.from Pit Face
Estimated Seasonal High Groundwater_
X.
Method Used; li)f�f >f°" _ in.
in. Depth to,soil'mottles:
Depth Observed standing in obs.hole: P ft
Depth to weeping from side of obs.hole: in. Groundwater Adjustment
Index Vdell#___._._ •Reading Dale:____ Index Wel!level,,,__ Ad.Wfactor _Adi.,Groundwater Level
.............................::::::::�::::�::::::::::;::.:::;•;::•;aa•o-st:;::855::::>:x.'t��:5$::ri>.:::::::>>isE'•>`�2s;;:i:ziCr>it�
1?>; is; 3 is is<;::?:i'i: 'is i?:i'•............................:' i ?i . :. :` i:^.:::C3iC i
.........................................
:....................................................
Observation Time.at 9,�
Hole#' '
Depth of Perc Time at`6
Start Pre-soak Time®
End Pre-soak
Rate Min./Inch
Site°Suitability Assessment: Site'Passed Additioi�al�Testing,Needed(Y/N)
Original: Public Health Division Observation Hole Data To fle; m0eted'on`Back
Copy: Applicant ,//�
:...:::::..:: .:::<:..;:..::.i':::.::;:.::::..:::::•':::;::.: •::::.:::: ;::•C::isLSi::::i:::::Yti;j✓::::;i:::;dith}::.`:e::1�i:i:::::>:'::::r:::::::}::::::j::?i::j:::::::j::::<::%c:::::::::::i":.
... .: 6. :.::::::..:.<.::::.::::::....:....;:.:::: .
.. .:
.:::.�.::::::•;:•::;;;;:«;;;;:>::>:�>::>:.>:::::;>: >r>;::::»»rs»>::>s»;::;«s>:;:•;::;;:•�u'�;:�::.::::::::.:.:::::: •:.:.........,....,......, Other
Bepth from Soil Horizon SoilliT A), i #•$€}Soil4Color,.a Sod
S face(in.) (.USDA). ;. (Munsell) . Mottling� (Structure,Stones,Boulderes.
o t'!k
lon
-r,
Olt
_ a 1.
!
Depth from Soil Horizon ' Soil Texture Soil Color Soil - . Other
i'Siiiface(in.) (USDA)• (Munsell) Mottling (Structure,Stones,Boulderes.
Consistengy.°°Gravel)
><
.. . :.. , :.:::.:::::.::.::.:::.::: .::: :.::.:::.:::...........::
om Soil Horizon.:::.............
D' from Soil Texlure Soil Color Soil Other
eplh (USDA) (Munsell) Mottling (Structure;Stones..Boulderes.
Surface
o si nc °o r el
Depth from Soil Horizon Soll texture Soil Color Soil Other
SuiPace(in.) (USDA) (Munsell)fiR
Mottling (Structure,Stones,Boulderes.
onsi en °o r e
FlaodiInsutance�.Rate Mari k
hz Above 500 year floodeboundary.•-No_ Yes
'Within 500.yearboundary No Yes
wiifiii;t00 year floodaboundary'No;G�? Yes
,.t 1•...v
Wepth of Naturally occurring Pervious Material
Does at least four feet of naturally occurring perviou material exist in all areas observed throughout the
area proposed for the soil absorption system?
1f,not,what is the depth of naturally occurring pervious material?
Qertiiication
certify that on (date)I Hve passed the soil evaluator examination approved by the
Departmeri of'Eh�vi o-'dhta-rPpdtection_and.that.the'°above analysis was:performed by,me•consistent.w;ith
the required training,expertise andyexperience described in 310 CMR 15.017.
Signature Date
Er
RJ
cO Certified mail Fee
Er C
$ExtraServices&Fees(check box,add fee asappropriate) NI3 M
` ❑Return Receipt(hardcopy) $rq
0 ❑ReturnReceipt(electmnic) $ Postmark -�
O ❑Certified Mail Restricted Delivery $ Here a�
p []Adult Signature Required $ Q
❑Adult Signature Restricted Delivery$ 1UL 2��6
Postage
m $
r 1 Total Postage and Fees
$ ASPS
Sent To
�hS.l sa_✓�__l-A
. .. ----------------------
� Street a d t. o.,or PO ox o.
a� r� ----------------------------------------
;ry S t, ;P 4 mills aa��f8
:., r r,
Certified Mail service provides the following benefits:
•A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
•A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
•Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®=pbstmarked Certified Mail receipt to the
■A record of delivery(including the recipient's retail associate.
signature)that is retained by the Postal Service- Restricted delivery service,which provides ,
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent.
important Reminders: Adult signature service,which requires the
■You may purchase Certified Mail service with signee to be at least 21 years of age(not
First-Class Mail®,First-Gass Package Service®, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
■Certified Mail service is not available for requires the signee to be at least 21 years of age_
international mail. and provides delivery to the addressee specified
■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark.If you would like a postmark on- ,
•For an additional fee,and with a proper this Certified Mail receipt,please present your ..
endorsement on the mailpiece,you may request Certified Mail Item at a Post Office-for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You Can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiere.
electronic version.For a hardcopy.retum receipt, r
complete PS Form 3811,Domestic Retum
Receipt attach PS Form 3811 to your mailpiece; IMPORTAMf.save this receipt for your records.
Ps Form 3800,April 2015(Reverse)PSN 7530-02-000.9047
SECTIONCOMPLETE THIS ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. X ❑Agent
■ Print your'nanie and address on the reverse ❑Addressee
so that we can return the card to you. B.5� iveyl by(Pr, d e) C. D f D livery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
-J-ohn f lsahel /,flu
mad
3. Service Type
ACertified Mail® ❑ "'Priority Mail Express
Registered gkReturn Receipt for Merchandise
❑Insured Mail 13 Collect on Delivery
4. Restricted Delivery?(Extra Fee) ❑Yes.
2' !7015 17'30'`0061 4989' 0298' I '�!
PS`Form 3811,July 2013 Domestic Return Receipt
UNITED STATE§-"P6SfiAt;S6;6hb - First-Class Mail
Postage&Fees Paid
USPS
ALIL. E Permit No.G-10
Sender: Please print your name, address, and ZIP+4®in this box*
Town of Barnstable
a Health Division
200 Main Street
Hyannis,MA 02601 S
#i k iililll�,k11 11ii11111'1I-P ikllil k ikll it 11il{1 1111l i I k k1171
I
IKE Town of Barnstable Barnstable
Regulatory Services Department AFAmericaCftyy
aaMSTABUE, I
9 `"S, ,�� Public Health Division m
F0 p 200 Main Street, Hyannis NIA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7015 1730 0001 4989 0298
July 20, 2016
John,& Isabel Deluca
15 Scarlet Lane
Marstons Mills, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 15 Scarlet Lane,Marstons Mills, MA was inspected on
07/08/2016 by Mark Polselli, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching pit or cesspool with high liquid level,<12" below inlet (per Town
Code 360-9.1).
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\15 Scarlett Lane Marstons Mills.doc
do
' Town of Barnstable
• anRtvsrnBce, +
Regulatory Services Department
i°rfn rug''
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-8624644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15,000) _
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a.cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
§360-9.1)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
o I
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal sy nz Ff4rin Nof for VoltlntarY Asses:;rnents c_
Property Address
W
Owner ON ner s Name "'O vl —_ ___a._°5.�/t4 C c! �Ti
information is
required for every // GL/.� I yvlS _�/
page. City lTo in - � � CD
Sratc Zip Code Date of In pest' n ice••
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.
fFing out Irn
A. General Information
fling out forme S 1-W 11-4a 3
on the computer,
use only the tab Inspector.
key to move your rA r ��SQ��
cursor-do not �1'
-Ijuse the return
key. Name of InspectorCompany Wrn�ew—
�-I/1110
Chi
AxI a -leeCompany Address
Otyfrown State Zip Code
t7� o?go__ �7�L
Telephone mber 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 CM 16.000). The system:
❑ Passes ❑ Conditionally Passes Fails
❑ Needs Further Evaluation by the Local Approving Authority
G X 1z�'
hs is Signature pate
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 god or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER 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.
t5i s•3M 3 Title 5 0fficlal Ins pection F ortrt Subsurfaoe Sewage Disposal System•Pape 1 of 17
ogy rs
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/S
Property Address
Ow ner Cw ner's Name 2/4 C
information is s � /�� O
requ'vedfor every
re/'f k � C TF
page. Gty/Town State Zip Code Dale f Ins tion
B. Certification (corn).
Inspection Summary: Check A,B,C,D or E J alwayscomplete 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:
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 ex0ain.
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 WR pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating tl iat the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
i-
A
t tea•3/13 Title 5 Offidal Inspection Form Subsurface Sewage Disposal Stem•Page 2 of 17
I
Commonwealth of Massachusetts
9�Ml T "Tide 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary
/Assessments
/S Scz:�t,
Properly Address
elvtC
information is Owner Owner's Name
required for every G/�'�-o rrs / !f �/� o�
page. Ckylrown State Zip Code Date of irfisnt on
B. Certification (corn.)
❑ 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 mannerwhich 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
tans.3M 3 Title 5 Official Inspecticn F o=Subsurfaw SewQe oisposal System.Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address ,P, ,
Ow ner G �� C
information is �
fOuvner:0blarfrie
required for every Gt✓l L-S $ !�
page. CRyfrown State Zo Code Date bfffispe6fjon
B. Certification cord.
Z 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:
*'b This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
colitorm 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
❑ up of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Di arge or ponding of effluent to the surface of the ground or surface waters
ue to an overloaded or clogged SAS or cesspool
El St 'c liquid level in the distribution box above outlet invert due to an overloaded
r clogged SAS or cesspool
Liquid depth in cesspool is less than 6'below invert or available volume is less
than day flow
t5ire•3l13
Tiite 5 Official Inspection Form Subsuface Savage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
lS
Property Address O
ON ner t°i
information is Oar nees Name ^I- �
required for every / Gt/'J T��f // 'S ( '
page. Cdy/ awn State Zip Code Date of Ins tron
B. Certification (corn.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
❑ 1; /obstructed pipe(s). Number of times pumped:
1- 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,
pr vided that no other failure criteria are triggered.A copy of the analysis
nd chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"nob 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.
t5ns•3(13 Title5 Official Inspection F arm Subswfaw Savage Disposal System•Page5of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /
Qnrner �e l✓1 C�
infotion is
Ow ner's Na",
requvred for every
i� l i��nS
page. CstylTown State Zip Code Date of In pest n
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes
❑ ping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ 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
nformation on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based,on:
❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
.330
DESIGN flow based on 310 CMR 15.203 for example: 110 gpd x#of bedrooms):
Mrs•3H3 Me50FfidA Irs pactianFamt SuGsvface Sewage Dispasal System-Page6of17
Commonwealth of Massachusetts
ya Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
j Z_
Property Address
Ow ner Ow ner s Name
infonriation is
required for every
page. City/Town State Zip Code Date of hsWctlon
D. System Information
Description: rl)
/ Su4r,4"4rj�i of
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 COY Vro
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes L9'No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 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:
tSrs-M 3 Tine 5 011cid Inspection Form Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
is _,
Property Address
Owner Ouvner'sNanyeS�P�1 /�
information is
required for every
page. Ctyf row n State Zip Code Date of Inspe tbn
D. System Information (coat.)
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
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of Sy
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 VA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(descri be):
t5n6,3M 3 rifle 50ffiaal Inspection Form Subsraface Sev09e Disposal system•Page 8 of 17
C Commonwealth of Massachusetts
ITTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
— 1-,r, sc d:W
Property Address J�
oL/2 /if C
Ow ner Ow ner's Name /
information is N ,�
required for every ct iY I / 1 ��
page. City/Town State Zip Code Date of InsoeVn
D. System Information (cont.)
Approximate age of all compprients, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade:
_ feet
Material of constructi;'4-0
❑ cast iron 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 pocate on site plan):
Depth below grade: feet
Material 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: —
Sludge depth:
L5m•3h 3 Title 5 orfiaal Irepection F o m SubsLrface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Forma .of for Voluntary Assessments
Property Address
olv ner �-e vt C �.
information is Oar nees Name /p
required for every Gi/f �I771A- /¢
page. City/Town State Zip Code Date of Inspe wn
D. System Information (cola.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle LZC
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Te-- h/ G w d --G PS l ocJ n dr7'76t-7
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
15re•3M3 Title501`fidal trupecdanFo=Subsuface Sewage Disposal system,Page 10 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l,S Sce::;.-e,
Property Address JJ
Owner
Ow ner's Name
information is r �✓I T�
required for every �/S n f � 1146
page. Cdy/Town State Zip Code Date aIn n
D. System Information (cons)
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 worldng 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
0M-W13 TioeWffidd ftpeofionForm Subsewe Se%%%eDisposel System-Page lid 17
I.
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address '—
ONner u
onr r>er's Name
information is
required for every cr
page. titylrown State Zip Code Date of Ifispecdon
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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;
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) pocate on site plan, excavation not required):
If SAS not located, explain why:
t5ns•3/13 Titles official Inspection Form Subsurface Savage Disposal System-Page 12 d 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
ON nor ON ner's Name
reformation is
equiredforevery
page- clyl-r°eNn State Zip Code Date of pe ' n
D. System Information (corn.)
Type.
leaching pits / number.
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
n n Zj` l o�✓ /!�1 lit✓ `'�
G a �JD k e- �/11/�C✓
ICA
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
tins•3M 3 Tide 50F6elal Ins pecdan Form Subsrrace SevageDisposal Sysdjm•Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/S �11
Property Address
ON ner e l/f G
information is �'"ner's Name I-
required forevery AIZ-
page. Cly/Town
State Zip— Code Date o Inspecti n
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.):
t9ns-3M3 Tme5orficial inspecdmForm Suhswace Sawagenspasat Sim•Page 14 d 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection, Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3
S
Property Address /
Carr ner l u G
information is (alv oar's ivarne /
requiredforevery G'ilr ✓j / f �o�-�Ic�
page- C RY/Town State Zip Code Date of Inspection
D. System Information (cono
Sketch Of Sew Disposal System: ProHde a view of the sewage disposal system, including ties to
at least rmanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
re lic water supply enters the building. Check one of the boxes below.
;handketch
in the area below
❑ drawing attached separately
Q
r
Q3 3 A77 7
t5ins•3M3
TitleSOffiaal Iris pectianForm SubsufaceSexegeDisposal System-Page 15af17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
ner0elLicel-
infomstionisO„ owner's Name
requvedforevey
page. Aty/Tow° State Zip Code Dat of inspection
Do System Information (cost.)
Site Exam
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells vim_
Estimated depth to high ground water. /C�
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
❑ erved site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board f/Health-explain: /
lcnS A
❑ Checked with focal excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
S-4. �- 1:5 "�19 A�_
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
�rls-W3 M850fficial InspecfionFortn SubsWaceSe eDi oral S wag sp ysrem•Page 16 of 17
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owrtet
�u every owner's t�rnei� "l �.-fX o✓If
page-
frown State __
ode [)ate of n
E. Report completeness Checklist
2 Inspection Summary:A, B, C, D, or E checked
0- inspection Summary D(System Failure Criteria Applicable to All Systems)completed
em h1brmation—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
fts-S13 TMOSO W U PGCff tFarM SubsulaW S8vMeD qMd SWM-Page 17 d 17
TOWN OF BARNSTABLE
LOCATION S r_,, Q_,At SEWAGE#
VILLAGE J�� 2Z� //i/i ASSESSOR'S MAP Ld VILLAGE
INSTALLER'S NAME&PHONE NO.-�Cr e 6c) � 1
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) f
BUILDER OR OWNERj�911�f'
PERMTTDATE- 75 COMPLIANCE DATE: F L�
'-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.ormithin 200 feet ofleaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of.leac g facility) _ Feet
Furnished by
.. t
Oro
��
r
] HM ] ] 61 H E A L T H M A S T E R ] HELP [ ]
R E C O R D ] ACTION ICI
r
For Parcel Number ] 148] ] 162] ] ] ] ] Rental Property(Y/N) [ ]
Owner; Name ] DACEY, BRIAN T TR ] Zone of Contrib (Y/N) [ ]
- Location 115 SCARLET LANE ] Contaminant Rel (Y/N) [ ]
Business Name [ ] Area Number
Contact Person [ ] Phone [000] [ ]
Fuel Storage Tank Permit [ ] Card on File [ ]
Perc Test Well Septic
File/Permit No. [P-8276 ] [ ] [95-437 ]
Issuance Date [ ] [0317951
Completion Date [ ] [ ]
Last Communications [ ] (MMDDYY)
Comments [ l
Cancel [ ]
NEXT SCREEN [HM ] ACTION [ ]
PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ] ]
f - -
09-23-1996 09:02AM FROM BAYSIDE BUILDING INC TO 7753344 P.01
Bayside Building, Inc.
P.O. Box 95 • 3 Bayberry Square • Centerville, Massachusetts 02632 Phone:508-771-1040
FAX: 508-775-0155
FF
PANAFAX MESSAGE
DATE: L;3/ `, r
TO: \1 C I(A• L)01')Q�flh
J
5 Caa h S ��s
TELECOPY NO.
FROM: IUonLV( FAX NO.—(508) 775-0155
MESSAGE:
FOLLOWING ARE / PAGE(S) (NOT INCLUDING THIS COVER) .
IF RECEIVED POORLY OR IF INCOMPLETE, PLEASE NOTIFY OUR
PANAFAX OPERATOR AT (508) 771-0894.
THANK YOU.
m
LJ_7' j._..... GA�TfYc✓J..J..T/i3 C�S�Q""� /Q o �-Fi
2. INSTALLATION OF SEPTIC SYSTEM TO BE IN
COMPLIANCE W[[H 310 CMR 15.M TITLE V.
PREPARED FOR
3. THIS PLAN IS NOT TO BE USED FOR PROPERTY
LINE DETERMINATION.
SCALE:..'s A Sw so DATE: ,�f.�/.G;'/y�i5 + S•
WELLER&ASSOCIATES
P.O.BOa w YAI010UTHP011T,MA.02675
(508)367,8131 3-9-5 S APPROVED BY:_
TOTAL P.01
09-23-1996 09:03AM FROM BAYSIDE BUILDING INC TO 7753344 P.01
110'1.x t.oG
TYST BY:WN,LLER&ASSOC.
W(,rN):Ss: c-" C�sae�
PERC RATE:—Z
sa.0
z�� .)vla5o.c 5/.cam
I coo
zi
J % $
I 0
I V.
a✓q7:£72 G'n..l_:a✓•rTF_k'F
10 '°:z
DESIGN DATA
ly DAILY FLOW{g)g vkJr� /i0 r j 3
LU SEPTIC TAM'.33— S I50%= �/95
USE:%aD6 7
LKACHivGFACILITY:
USE:
S CAPACITY:
tea, c SiDEWALL:��°'.S,.,^.S• Y7/
40 744
TOTAL:
4�y,
gL;,4'aw-"4,1i-41
PIPE TO BE LAID I'LAYER OP3B'PWTONS
LEVEL Folk v OvT OF OVER 3ia^.1 ill* wASHED
DISTR3L'MONBOa STONI:ALL AROM
TOP OP POUND.
f�ELF
Z.
ALL PB'E TO ffi 4•DUI.SCH 40 PVC
RAZE ALL AM1CAISLE MA 4n04v. /C+�
COVERS TO WITDTN 6. OP FINISH
CRUDE
TILIS SYSTEM 13 NOT DESIGNED FOR
R'HB USE OF A CA'P-A Z DISPOSAL
SEWAGY SYSTEM PROFILE
SCALE: 1"=10'
GENERAL NOTrS
?'i_: •'"' `' 1. CONTILACTORTOBE RESPONSIBLE FORTHE
'h �•^.._ �:, �,' LOCATION OF ALL UTTGITIVS,ABOVE AND
SITE-SEWAGE PLAN UNDER CROUND,PRIOR TO ANY CONSTRUCTIC
FOR
OR EXCAVATION.
3�s11.gs 2. INSTALLAT'(ON OFSEP'rICSYSTEMTO BE IN
COMPLIANCE WITH 310 CMR 15.00:TITLE V.
PREPARED FOR
THIS PLAN IS NOT TO BE USED FOR PROPERTY
LINE DLTERIrUNATION,
SCALE:�05.✓o:0-0 DATE: smvit c
WELLER&ASSOCIATES n
P.0.BOX 119 YARMOUT1I1,011T,MA.02675
(508)3624131 3-9-5 s APPROVED BY:_
TOTAL P.01
`�r TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE .� 1� A/ s ASSESSOR'S MAP
INSTALLER'S NAME&PHONE NO.- -30t?1
SEPTIC TANK CAPACITY 0
LEACHING FACILITY: (.type) / (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 7 I k!J COMPLIANCE DATE: `I J 0
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 4 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 leac ' g facility)) G , Feet
Furnished by
-- /9
Lloj.z� -
36
1
E G E N SYSTEM DESIGN: SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES
MARKED WITH MAGNETIC TAPE OR
COMPARABLE MEANS FOR FUTURE LOCATION. NAVD 88
PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) 1. DATUM IS
99— EXISTING CONTOUR GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE
2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING
X 99.1 EXIST. SPOT ELEV. EXISTING 3 BEDROOM DWELLING TOP FOUND. EL. 58.5 FILTER FABRIC OVER STONE oc a ok 5tteet
— 99]— PROPOSED CONTOUR SIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD \ 2% SLOPE REQUIRED OVER SYSTEM 56.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ���5 R 0
MINIMUM .75' OF COVER OVER PRECAST �o
[ DE 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS ace ane
NOTE: 2" MIN. WALL
198.4] PROPOSED SPOT EL. USE A 330 GPD DESIGN FLOW THICKNESS REQUIRED BLOCKS OR TO BE AASHO H-12 p�
55.37' PRECAST RISERS o
4"�SCH4Ci PVC MORTAR ALL rJ 9Sh/P
TH1 TEST HOLE SEPTIC TANK: 330 GPD (2) = 660 '' s2"MMIN.SUMP DIM. PIPES LE`✓EL 1ST 2' 4' COMPONENTS H-10 5. PIPE JOINTS TO BE MADE WATERTIGHT.
�ENj D TYP. INV'S EL. 52.2 4'
SIDES 53.03' a
`� 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH
2� SLOPE OF GROUND USE EXISTING 1000 GAL. SEPTIC TANK P° °�°�°
10" �a" ° ° ° ° ° ° ° ° 310 CMR 15.000 (TITLE 5.) p r
**EXISTING
TEE a000 000jl � 00000 >o°o°a°o° } c
TEE 53.97
SEPTIC TANK o 0 0 0 0 o° mmm��0��0 o o WATERTEST D'BOX o >°°°°°°°° ° ° ° ° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
0 0 0 0 0 0 �oDo��oDoo ���0����� ° ° ° °° ° ° ° ° ° BE USED FOR LOT LINE STAKING OR ANY OTHERGAS BAFFLE .., o 0 0 0 0_ o 00 0 O O o 0 0 0 0° ° ° ° ° ° ° ° �r
UTILITY POLE LEACHING: FOR LE`dELNESS N ° °°°°°°°° 50.2 PURPOSE. \a5
FIRE HYDRANT SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD 52.47 52.30 O pr
A
r'' 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. Locus
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING BOTTOM 25 x 12.83 (.74) = 237 GPD p /
3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. LH-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. •�o'� pt
(2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED r o
TOTAL: 472 S.F. 349 GPD ALL AROUND PRECAST STRUCTURES WITHOUT INSPECTION BY BOARD OF HEALTH AND
6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' PERMISSION OBTAINED FROM BOARD OF HEALTH.
COMPACTION. (15.221 [21)
USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) Ti 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
*THE INSTALLER SHALL VERIFY THE WITH 4' STONE ALL AROUND
DIGSAFE (1-888-344-7233) AND VERIFYING THE
LOCATIONS OF ALL UTILITIES AND ALL LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES LOCUS MAP
BUILDING SEWER OUTLETS AND PRIOR TO COMMENCEMENT OF WORK.
6 8 45.0' BOTTOM TH-1 SCALE 1"=2000't
ELEVATIONS PRIOR TO INSTALLING ANY ( � SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUIND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
PORTION OF SEPTIC SYSTEM MA LEACHING REMOVED 5' BENEATH AND AROUND THE PROPOSED ASSESSORS MAP 148 PARCEL 162
APPROVED DATE BOARD OF HEALTH FOUNDATION— EXIST SEPTIC TANK 22 D' BOX 12' FACILITY LEACHING FACILITY.
**INSTALLER SHALL CONFIRM MINIMUM SEPTIC 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY
FOR RE—USE. REPLACE WITH 1500 GALLON REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF
NOT SUITABLE
O"� V
h0 L—4; 1,
56 DRAINAGE TEST HOLE LOGS
EASEMENT
/ ENGINEER: CRAIG J. FERRARI, SE #13871
\ /
WITNESS: DAVID W. STANTON RS
DATE: 10/7/2016
PERC. RATE < 2 MIN/INCH
_
CLASS I SOILS P# 15161
ELEV. � ELEV.
V O" `V 56' 0" `V' 56
57 ss Q�� A A h� O LS
•
. LS
O 12 15
OSL SL
57� / " .9
10YR 5/6 53 ' 1OYR 5/6
25
M 28 53.6,
�M C C
P PERC
BENCHMARK:
CBDH ELEVATION M/ \
—56.2 NAVD88 � O
MS
MS
EXISTING
DWELLING E E
— � E
\ M/ E F ---_ �
TOF = 58.5 E E /E ---_ 10YR 7 4 /
10YR 7 4
cV / E
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DATE: OCTOBER 7, 2016
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DATE DANIEL A. OJALA, P.E., P.L.S. 939 Main Street ( Rte 6A)
DCE # ' 6-29,7 YARMOUTHPORT MA 02675
16-297