HomeMy WebLinkAbout0149 SCHOOL STREET - Health 149 SCHOOL STREET
Marstons Mills
A = 046 - 013 - 001
0
TOWN OF BARNSTABLE
LOCATION �� �Sr SEWAGE #
VILLAGE IL4 ASSESS R'S MAP & LOT D°f Ga 013 ��f
INSTALLER'S NAME & PHONE NO. - Al Zf f - 60
-4 le
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ;i- �d ® (size)
NO. OF BEDROOMSc_PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
���a � �
� X�
V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Vol untary'Assessments
149 School st 3>
- ------- ---
Property Address
CA
Kevin Minnigerade
Owner Owner's Name
information is
required for every Marstons Mills _ Ma 02648 _ . 3/23/17
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be alterRin any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information 0
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
raa Company Name ----. -- -- —
8 Johns path
Company Address
arum S Yarmouth _ _ MA 02664'
City/Town State Zip Code.
508-364-9587 S113522
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:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
_
.
3/24/17
Inspector's Signature Date v
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
I itle 5 Official, Inspection
Subsurface Sewage Disposal.System Form = Not-for Voluntary.Assessments
149 School st
Property Address
Kevin Minnigerade
Owner Owner's Name ---- ---- ----- -----
information is
lil required for every Marstons Mills Ma 02648 3/23/17
page. «; City/Town State Zip Code Date of Inspection
B. Certification (cont.) — ---
Inspection Summary: Check A,B,C,D or.E/always complete all of Section D
A) System Passes: .
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 31.0 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
..,System includes two 6x8 Cesspools. The first acting as a septic tank. The second pool is clean and
Staining no higher than six inches off the bottom. Both 4" lines were replaced in 2002
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):
i
Gins•3/13 Title'5 Official Inspection Form:Subsurface.Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
w
We icl l Inspection Form - .
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
149 School st
Property Address
Kevin Minnigerade
Owner Owner's Name --- — —
information is required for every Marstons Mills Ma 02648 3/23/17
— -------------------------------- -----
page. City/Town State Zip Code Date of Inspection
S. Certification (cont.) --- —
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) _ System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction'is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y n❑ 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 Massa chus.etts..:
W Tide 5 Official Inspectionform
Subsurface Sewage Disposal System Fo,fm - Not for Voluntary Assessments t , .
a° 149 School st -
-Property Address ---
Kevin Minni erade
Owner Owner's Name'
information is
required for every Marstons Mills Ma 02648 _ 3/23/17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public !Hater Supplier, if any)
determines that the system is functioning in a manner that protects the,public health,
safety-and environment:
❑ The system has aseptic 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**:
Methbd•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 Ap
plicable t
i ) Y o All Systems:
pp Y
You must indicate"Yes" or"No" to each of the following for all inspections:
Ye
s No
El ® 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 '/2 day flow
15ins•3L13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Tif6c 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.
149 School st
Property Address
Kevin Minnigerade
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 3/23/17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last year NOT due to.clogged or
El El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17,
- Commonwealth-of Massachusetts
itle 5 Official Inspection For
Subsurface Sewage Disposal System Form,,- Not for Voluntary Assessments
° 149.School st
Property Address
Kevin Minniqerade
Owner Owner's Name - - -- ------- -
information is required Mills Ma 02648 3/23/17
required for 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?
- ® ElWere 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)]
D. System Information
Residential Flow Conditions:
- Number of bedrooms (design): 3 --=— Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203{for example: 110 gpd x# of bedrooms): KO
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forte
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4
149 School st
Property Address
Kevin Minnigerade _
Owner Owner's Name
information is
required for every Marstons Mills Ma, 02648 3/23/17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Vacant. f
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 av Ilable last 2 years usage d 158 Gpd
9 a� ( Y 9 (gP ))�
Detail:
�..
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:-
Type of Establishment: —
Design flow (based on 310 CMR 15.203): Gallons per day(gpa)
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
r ,
Commonwealth of Massachusetts
Toile 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Nqt for Voluntary Assessments ,
w1.49..School st _
Property
Address
_ Kevin Minnig erade
i
Owner Owner's Name
information is Marstons Mills Ma - 02648 3/23/17 _required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date --
Other(describe below):
} t
General Information
Pumping Records:
Source of information: None provided System is dry- —
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
Official
o Inspection
rn
Subsurface Sewage Disposal System Form Not for Voluntary Assessments t
149 School st ;
Property Address
Kevin Minnigerade
Owner Owner's Name
information is _Marstons Mills. Ma 02648 3/23/17
required for every _-
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:
50+
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer (locate on site plan):
Depth below grade: 2
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.):
New mainlines in 2002
F.
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other.(explain)
0.
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: ----
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
•. h
Commonwealth of Massachusetts
Title 5 Official In's- pectionform
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a 149 School st
Property Address
Kevin Minni erade
Owner Owners Name
information is
required for every Marstons Mills _ Ma 02648 3/23/17
page. City/Town State Zip Code Date of Inspection
D.. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum"thickness .------ - ----
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.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness - --- ---- —----- --
Distance from top of scum to top of outlet tee or baffle ----- ---
Distance from bottom of scum to bottom of outlet tee or baffle —
Date of last pumping:
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
gills 5 Official Inspection Form
Subsurface,,Sewage Disposal System Form - Not for Voluntary Assessments
o° w 149 School st
Property Address
Kevin Minnigerade
Owner Owner's Name
information is Marstons Mills _Ma 02648' 3/23/17
required for 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.):
t
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•3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
=\
Commonwealth of Massachusetts
W title 5 o icialI pec i n Form
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
149_School st_ _
Property Address
Kevin Minni erade
Owner Owner's Name
information is
required for every Marstons Mills — _ Ma,_ 02648 3/23/17
page. City/Town 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 NA
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) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Tiles 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
149 School st
Property Address
Kevin Minni erade _
9
Owner, ---------------—.—-------------------------..--- --------- --------
Owner's Name
information is required for every Marstons Mills Ma 026.48 3/23/17
___ ----- ------ --- ----------------- ---
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.) -----
Type
❑ leaching pits number:`
❑ leaching chambers , number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,.dimensions:
® overflow cesspool number:.
1 6x8
❑ 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.):
Cesspools are dry
Cesspools (cesspool-must be pumped as part of inspectio.n).(locate on site plan):
Number and configuration 2 inline
Depth —top of liquid to inlet invert Dry
Depth of solids layer
Depth of scum layer
Dimensions of cesspool 6x8
Materials of construction Block
'Indication of groundwater inflow ❑ Yes ® No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17
r
Commonwealth of Massachusetts.._.*�
14V Thee 5 Official Inspection Forte
Subsurface Sewage Disposal System Form Not for Voluntary Assessment's
149..School st -
Property Address -- ---------- --- ----—
_. _Kevin Minnigerade
Owner Owner's Name
information is
required for every Marstons Mills _ _ _ - _ — Ma— 02648 3/23/17
page. City/Town State Zip Code Date of Inspection
. 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:':
lid
i
Sins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title icialInspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
149 School st
Property Address ------ - ----- — --- .
Kevin Minnigerade
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 3/23/17
------ ------- ---- --------- ------- ------- - -
page. City/Town 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 bu.ilding,..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
157
W Title 5 Offidal Ihspection Foy
Subsurface Sewage Disposal System Form - Not for�Voluntary Assessment
e, 149 School st
Property Address --------------- -------------- --- ---------
Kevin Minnigerade
Owner —.------------------- ----------
Owner's Name --
information is
required for every Marstons Mills Ma 02648 3/23/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ .Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15+
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: pate — - --
® 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 h y t e high ground water'elevation:
Nearest water venue is well below 15'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
l .
y G v
TOWN OF BA]RNSTABLE
LOCATION �� }Cx��- �� SEWAGE#
VILLAGE j �t'rSSESSOR'S MAP&PARCEL
r INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type_) (size)
NO'OF-BEDROOMS 3 _
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
P on
rivate Water Supply Well and Leaching Facility(if any wells exist
site or within 200 feet of leaching facility) Feet
D Edge of Wetland and Leaching Facility(If any wetlands exist within
r +'Y 300 feet of leaching facility) Feet
Y RTIDNT1QT=TI RV
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Is Subsurface Sewage Disposal System Form - Not for Voluntary{Assessments
°�.• 149 School st
Property Address
Kevin Minnigerade
Owner Owner's Name
.information is
required for every Marstons-Mills" Ma 02648 3/23/17
page. City/Town State Zip Code Date of Inspection
E. Deport Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Apprrcable'to All Systems) completed
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or at in separate file
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
AsBuilt Page 1 of 2
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE �k ASSESS R'S MAP & LOT DYG"013
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) !p o e> (size)
NO. OF BEDROOMS C�l _PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER � SQ�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=046013001&seq=1 4/4/2017