HomeMy WebLinkAbout0150 SCHOOL STREET - Health reeteolStpLA =
cMss
46 003001
D fl 603
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Gn
ac 150 School st
Property Address r�
Dan Chesler
Owner Owner's Name
information i as Marstons Mills 1� Ma 02648 8/23/16
required for every _
page. City/Town State Zip Code Date of Inspect
t77
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. General Information
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
Q Company Name
8 Johns path
Company Address
S Yarmouth Ma 02664
City/Town State Zip Code
508-364-9587, S103522
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
Tittle 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
`~ 8/24/16 "
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 School st
Property Address
Dan Chesler
Owner Owner's Name
information is _
required for every Marstons Mills Ma 02648 8123/16
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System contains a 1,000 GI septis tank as well as a concrete distribution box and two 500 GI leaching
chambers.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 8/23/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.): -
❑ Observation of sewage backup or break out or high static water level in the distribution box due
-to-broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth-of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that-the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
I .
❑ 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 v
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*' This system.passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid.depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is required for every Marstons Mills Ma 02648- 8/23/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the.last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® 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 an.d.th.e.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, ycu must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
page. Clty/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?
® 0 Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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): 330
t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M a 150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 8/23/16
page. C:ity/Town State Zip Code Date of Inspection
D. System Information
Description:
System contains a 1,000 GI septic tank as well as a concrete distribution box and two 500 GI leaching
chambers.
Number of current residents:
Vacant
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
Seaso.naluse? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage d 109 GPD
9 ( 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(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealthp of Massachusetts
2-3
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
page. Clty/Town State Zip Code Date of Inspection
D. System Information (cost.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: None provided
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
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every
Marstons Mills Ma 02648- 8/23/16
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:
10 Years
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
1
Depth below grade: feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1feet
Material of construction:
.® concrete ❑ metal ❑.fiberglass ❑ polyethylene ❑ other (explain)
1,000
If tank is metal, list ao}e: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
(Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
53
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
page. CityFrown 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 24
Scum thickness 3"
Distance from top of scum to top of outlet tee or baffle 42
Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No evidence of Ieakinq,Tees and or baffles in place at time of inspection
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain).-
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma' 02648 8/23%16
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.):
Tees are in place and levels are normal.
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
L
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
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 Level and at normal level
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills- Ma 02648 8/23/16
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
2
❑ 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.):
Chambers are clear clean and dry
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
No ponding no break out
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Assessing As-Built Cards Page I-of 2
TOWN OF 13ARNSTABLE
LOCATION /5'0 RAgo( Sf SEWAGE It
VILLAGE 1114(s m M(1/1 ASSESSOR'S MAP&LO��iO3_c�
INSTALLER'S NAME&PHONE NO. r SW e
SEPTIZ TANK CAPACITY &/0 1dQQ Sa t( )
LEAC_-DNG FACILITY;(typo)
y O.O.?BEDROOMS_
UII DER OR OWNER
PERMCCDATE: ? US~ COMPLIANCE DATE: 5 2 �j�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �� Feet
Private Water Supply Well.and,Leaching Facility (lf any wells exist
on site or within 200 feet of leaching facility) N° Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
Na
witt:in 300 feet of leaching facility) Feet
Furnished by
�A
ca
s1'G
31 .E
httn://www.tr)wnnfha.rn.ta.hle.n-,/A.-,e.-,ing/T4Mdi.qnlay.2..n?manna.r=046001001&.qeo=1 9/19/2016
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
�V 150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
-------------------------
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 8/23/16
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: 10+ ft
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: Jan 2015
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Test hole data on plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
150 School st
Property Address
Dan Chesler
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 8/23/16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed..
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
IL
IL TOWN OF BARNSTABLE
L@r'ATION I � a L -,-!54- SEWAGE #
VILLAGE. lCU` ASSESSOR'S MAP & LOT Lf 10"
INSTALLER'S NAME &. PHONE NO.
SEPTIC TANK CAPACITY CJPb,
'LEACHING FACILITY:(type) . (size)
NO. OF BEDROOMS PRIVATE WE OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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INSTALLER'S NAME&PHONE NO. �' c,cut n �- -rok ya,r 5/Oa2y
SEPTIC TANK CAPACITY #/D /SOD sal
LEACHING FACILITY: (type) CA&MW_ (size) /Z X otf
t: NO. OF BEDROOMS
BUILDER OR OWNER md4 41L,5
PERMITDATE: I -5 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility '�d Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) No Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
N J
within 300 feet of leaching facility) Feet
Furnished by
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;Q Ai 41.7 c.a no
s ,
3 a
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No. CJU3— Fee Id o
TH12 COW14.IWEALTH OF MASSACHUSETTS Entered in computer:l
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for 30i5pool bpotem Con,�tructton Permit
Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( )XComplete System O Individual Components
Location Address or Lot No. b Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel
d - a),5 � E
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
C('1P 6Wk D E E►JT. LLC 51 ol\e cvou, SQ C.S.
5 ((
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(P/A
Other 'lope of Building NO ti e No.of Persons L Showers(1,/) Cafeteria( k,S
Other Fixtures c A-..,. 6 6-"r c"c-rj 3 ,,,1s, L'Au ti laY
Design Flow 2)3 O gallons per day. Calculated daily flow 331 . 5 -gallons.
Plan Date 6 Jag I o5- Number of sheets 1 Revision Date
Title r�qgA ()R a,oacw
Size of Septic Tank ew 6 stsi c„_A.i E,,j k Type of S.A.S. " Soo �G \kc�C�IwS
xa
Description of Soil _ �o Drams
ia� x a s' '
Nature of Repairs or Alterations(Answer when applicable) 31U
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 to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date -
Application Approved by
Application Disapproved for the following reasons
Permit No. Go. q Date Issued
ATo. UU �[o� \ ^
_.. ! Fee /6�
THc led"W41ONWEALTH OF MASSACHUSIr, Entered in computer:6,Z
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for Mood *pgtem Congtruction Permit
Application for a Permit to Constrict( . )Repair(U)Upgrade( )Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. 1GOOwner's Name,Address and Tel.No.
Assessor's Map/Parcel t-A ccS*ac-,S �-
- 00 1 f1Nt
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t
Cell-Cali f)E EQT. LLC S001Y I&JU, S\11C S.
a 5 Set
Type of Building:
Dwellings No.of Bedrooms_ Lot Size _sq.ft. Garbage Grinder Other (�1
a of Building. + l�)n I c No.of Persons Showers(Type � ✓) Cafefena( p4 .
Other Fixtures t 1
Design.Flow 2) O t gallons per day. Calculated daily flow ?, . S gallons.
Plan Date 1 n I t Number of sheets l Revision Date
Title _e-n A
Size of Septic Tank tsj p, 1 k Type of S.A.S. no C,Q. \ r 5
Description,of Sod
I t
Nature of Repairs or Alterations(Answer when applicable)'��� ,•� CAOKC4�
Date last inspected: {{
Agreement: 4
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 to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed C Date S
Application Approved by _� _ Date
Application Disapproved for t9 following reasons
Permit No. 7 r,n r- c/ Date Issued `-
— — --- -- --- --- —THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( )Upgraded(�)
Abandoned( )by u%. _ ,)C S
at 1 S y <CU--X !;S dr e_T ^1 `—fD M'.��3 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - 2,2 V dated E- 3 'go c"-.
Installer 4t-al 'J,4y Designer
The issuance of this permit all no be construed as a guarantee that the �terYt nc 'on as designed.
Date /�T7 L��a Inspector�-.
No. 2()n c� Fee J00
THE COMMONWEALTH OF MASSACHUSETTS
t
-PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigogal *pgtem eongtruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( �)Abandon( )
System located at `! , S.t L » STc keP.*r M a
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
w comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of th*spermit,A
Date: Approved by �1 i
TOWN OF BARNSTABLE
LOCATION.. /0' Sc�ao l Sf' SEWAGE #
VILLAGE /1141s �llr�/� ASSESSOR'S MAP & r(V3—DO
j
INSTALLER'S NAME&PHONE NO._ 4c
SEPTIC TANK CAPACITY #/D / dp
LEACHING FACILITY;.(type) c? -SOd G (,�4atit � (size) Jz r yd S
NO. OF BEDROOMS__A
BUILDER OR OWNER CkL i6d r
.. FERMITDATE: �1.5✓ COMPLIANCE DATE: 2 0-5—
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility // Feet
Private Water Supply Well and LeachingFacility ty (If any wells exist
on site or within 200 feet of leaching facility) Na Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) ~4
Feet
Furnished by
A '� v",7 c.a 39.0
A f 54,a
s g'13
a ►
� a aa•c�
33 9
4', . 3a .?
f 1� 9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
c�
I, rAs m,r,i� E - ,hereby certify that the engineered plan signed by me
dated concerning the property located at
meets. all of the
following criteria:
• This failed system is connected to A residential dwelling only. There are no.commercial or
business uses associated with the:dwelling.
• The soil is.classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will-be located no less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation +adjustment for high G.W. 3, G . _ , G
DIFFERENCE BETWEEN A and B ®
SIGNED: DATE: _ 5 Cj
T
NOTICE
Based upon the above information;a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptclperceX=p.doc
t
Permit Number: Date:
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: oC Lot No, `t?
Owner: Address: �r�
Contractor: ro_ n�.. �1�`CS Address: (, aDL-J CYNcNk
Notes: ca^\
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date S o'er
month/dal/year
STEP '2 Using Water-Level Range Zone
and Index Well Map locate
sitel and determine:
OAppropriate index well.............................................. ,S3
OBWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...................... 41-4
��� mo th/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and!water•level zone (STEP 26)
determine water-level adjustment ................ 7ee
STEP 5 Estimate depth to high water
by subtracting the water•level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1 ......................... .......................................r\.....................
r;
Figure 13.--
g Reproducible computation form.
15
Town of Barnstable
°Ft"Et°y Regulatory Services
Thomas F. Geiler, Director
* BMWSFABLE,
�cbA '& ���� Public Health Division
rFD 39. Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 5/23/05
Designer: Shay Environmental Services, Inc. Installer: Capewide Enterprises
Address: P.O. Box 627 East Falmouth Address: P.O. Box 763
MA 02536 Marstons Mills, MA 02632
On 5/23/05 Ca ewide Enterprises was issued a permit to install a
(date) (installer)
septic system at 150 School Street, Marstons Mills, MA based on a design drawn by
(address)
Shay Environmental Services, Inc. dated 05/20/05
(designer)
XX_ 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 tank.
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 system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
OF U43. ,
CARMEN
( taller's Sign t re) F_
SHAY N
No. 1181
� a
�GtSTER�
(Designer's Signature) (Affix D r p 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
*RAND
3-24- DIAM. ACCESS MANHOLES
10, 5*-----7
t
I i '-,-
;a _:Ii
VENT PIPE (0 Least 24 inches tall SECTION A -A
10' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Schedule 40 PVC */Charcoal Odor
Existing Found _h
Otion use to septic tank CHAMBERcoyer must be 7F,1 t er PROFILE VIEW OF LEACHING SYSTEM INLET 4-
Septic tank covers must be D BOX cover must be with in 6 in� ns d grade INLET T ISO school in
FOUNDATION ELEV, 6 inches
TOP OF 100.00 (Assumed) Within 6 Inches of Finish Grade W r, ade 0 g TANK, Im
Grade over Septic Tank 98.00 nish Grade Gr o� Bo 7.50 rode CIAI Ei 97.50 THE ACCESS COVERS FOR THE SEPTIC i.
q l l W-Md P".l I DISTRIBUTION BOX AND LEACHING COMPONENT ba
-77
SHALL BE RAISED TO WITHIN 6" OF
INSPECTION cover must
FINISHED GRADE.
within 6 ii of finished rode
S 0.02 3 HOLE H 10 STEEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TiTE GAS BAFFLES OR EQUALS
Top of SAS-Etlill
f T, BO 3' Maximum Co�er ON ALL OUTLET TEE ENDS
0 16' NEW S�0-01 or Greats 0.010- per foot A PLAN VIEW
EXIST FI!L 11� in 1,500 CAL. cz) C:3 L=
WD C4 CM CM C�
FROM LXIST FOUNDATION SEPTIC TANK C3 E:3 i =1 3-24" REMOVABLE COVERS
20' Effil Depth ED 0
0 20'
a-Be%. 2 Units @ 8.5' 17'
H-10
CONCRETE FULL F1__ >. 0) 4.
0) 15' 5 3.5' Lr, 'T":
> > A C) INLET 2' min. Inlet to outlet r in GENMAL NOTES
6 in.of 3/4"-1 1/2" > - ------ In
SYSTEM PROFILE 0 0 a) 12'- 11 5 OUTLEI
> compacted stone T Ef'rective Length INLE 7 1 110 T,in.T_J LiaWd 1.�ei_ .:, _fINLEr
14-
Effective Width LI -- 1. Contractor is responsible for Digsafe notification
0 5' -7-
Not to Scale I.S >; ..4 t 1 45' -7* 1 nd protection of all underground utilities and pipes.
T SOIL ABSORPTION SYSTEM (SAS) a
11 E _C" rrin 2, The septic tank and distribution box shall be sell
Liquid depth
6 in,of 3/4"-1 1/2" 0 500 C H-20 LEACHING UNITS / WIGGINS PRECAST
leve on 6" of 3/4"-1 1/2" stone.
compacted stone M
IRON PIPE 3, Backfill should be clean sand or gravel with no
NOTE: ALL COMPONENTS MUST HAVE RISERS TO W1 THIN 6' BELOW GRADE Bottom of Test Hole 1 Elev.= 86.50 Not to Scale M
stones over 3' in size.
FND u ---I---------f;;- ------ 4. This system is subject to inspection during, instaliat,on,
v Obs. Gro jwo*er t Hole 1 Ell NONE OBSERVED
by Carmen E. Shay - Environmental Services, Inc.
5� The contractor shall install this system in accordance
CROSS SEC I-ION END-SECTION
with T�t!e V of the Massachusetts stale code, the aDproved pion
and Local Regulations.
I
T�PICAL 1500 GALLON1 -SEPTIC TANK 6. If, during installation the contractor encounters any
soil conditions or site conditions that are different
NOT TO SCALE] from those shown on the soil log or in our design
installation must halt & immediate notification be
(H- 10 LOADING)
made to Carmen E. Shay - Environmental'Services, Inc.
7P No vehicle or heavy machinery shall drive over the
PERCOLATION TEST I septic system unless noted as H-20 Septic components.
8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
Dote' of Percolation Test: MAY 20, 2005 9, All DistribuUon Lines shall be 4" diameter Sch. 40 NSF PV11 pipes.
Test Performed By: CARMEN E, SHAY, R.S., C.S.E. 10. All solid piping, tees & fittings shall be 4" diameter
Results W7tressed B)r. WAIVER (Per Barnstable BOH) Schedule 40 NSF PVC pipes with water tight joints.
0 Excavator: Shay Envirormnetcl Services, !no. 11. SITE and Surrounding Properties are Connected
Percolction Rate: Less Than 2 min./;ncri 0 48" BELOW GRADE. to Municipal Water.
0
0 1?19 Test Hole I
No. 1
DEPTH SOILS I
AND
t 1* 17� ---- -- THE PROPEi LINES ARE APPROXIMATE
I �c 0 1 97.501 COMPILED FROM THE SURVEY PLAN GENERATED BY
JLoomy Sand!
BAXTER & NYE, INC. OF OSTERVILLE, MA ENTILTED
10 YR 3/2�� "SUBDIVISION PLAN OF LAND IN BARNSTABLE, MA
co
o,-5" As 97.00
/0� DATED 04/27/1990 LC 42257-B
> RON Pli Sandy Loa IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
<
THE SEPTIC SYSTEM INSTALLATION.
FND 10 YR 5/1
5"-21
�95.75
5 it
EXISTING CESSPOOLS TO BE PUMPED OUT AND FILLED IN P
LACE
2.5 Y 8/6
21"-48' Ci 93.501
-------------------- -Cool
Med
A-4 I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
Sand
FROM, THE EXISTING CESSPOOLS TO BE DISPOSED
2.5 Y 7/4
OF AS PER'BOARD OF HEALTH SPECIFICATIONS.
17. 48"-132 C2 86.50
GRAVEL
DRIVEWAY
EXIST.
GARAGE Cb ASSESSORS MAP 046 PARCEL 003/001
ZONING - RESIDENTIAL
FLOOD ZONE C_
I Perc #1
Depth, to Perc� 43" to 66"
ij Perc Ratl mh./inch,
Groundwater Not Observed
-TOM THERE ARE WETLANDS LOCATED WIIHIN A 200' RADIUS
I y I/ I T HED B0 OF TEST HOLE Elev. 132" OF THE PROPERTY AND ARE AS SHOWN
USTED 20 Elev. No Adjustment Required.
ADJ
140'
/APPRCX/
�c
it
RADIO
EXISTING I
TOWER
2 BEDROOM DECK
D1STRI81J'nON 0 ES MOO THE
` END
HOUSE 1500 go I ALL OUTLET PIP
Septic I nk LE'
OX SHALL BE f2l'
#150 i SET LEVEL FOP AT LEAST 2 FT- CONCRETE COVER
3 - 5* OUTLET 2'
6' 00 KNOCKOUTS
DENOTES PROPOSED
Fi
Q_-Sspool SPOI GRADE
----------
f 3.5 OU TLE 12 INLET
----------------
IZ5
_ES EXISTING
DEN07
X 104.46 1
4 SCH. 40 SPOT GRADE
0 / PLAN SECTION CROSS-5ECTION
PL PROPERTY LINE
1 22' Failed
TEST HOLE #1 Cesspool OADIN
1 C 1 G PROPOSED CONTOUR
ELEV.= 97.50 3 HOLEDISTRIBUTION BOX
NOT TO SCALE
97- - - - - -97 EXISTING CONTOUR
CB D.H.
FND
12
IHO HCLE
0 DEEP TEST
-ION TEST LOCATION
Dl Calculations PERCOLA71
Number of Bedrooms� 2 Equivalent lo 220 GaVDay (330 Go!./Day V�'l per Title V�
FENCE
LOT #7 Garbage Grinder: No
Lecching Capacity Proposed: 330 Go!./Day Vinirnum. (Min, Per Title V,
72,119 Square Feet
25' Septic Tank 2 x 330 Gal./Day = 660 USE NEW .1,5000 GAL. Septic Ton;4. JEIR WELL
SOIL ABSORPTION'AREA: Using percolation rate of <2 ,nnin./inclh PRIVATE DRINKING WAI
Bottom Area: 0.74 gal/sq. ft. x 300sq. ft 222.00 gallons N I
Sidl Areia: ft, 109.50 gallons _V I
0.74 gal./sq. ft. x 148 sq. S
Providing: 331 50 gcllors
U
-AST 500-C UNITS, 'E DEPTH, NO. D 4r E: DEFINITION
se: (2) PPFCC HAVING A 2' EFFEC�lv
TO BE USED W1171 3.5 OF WASHED STONE ON THE SIDES AND
PIROJECT BEI�CHI MARK t
4' OF WASHED STONE ON THE ENDS.
JUNDATION
-P OF FC
100.00 (AsSLIrned)
cl�
_4
PROPO `� ED
1 \ 1 L_J o
SUBSURFACE SEWAGE DISPOSAL S�' S ! L_
OF
M R . i/X CH E S L EIR
# 150 SCHOOLS STREET
hl
MARSTONS MILLS, MA
P . 0 . 'BOX 236
CB D.H.
FND
PREPARED BY:
MARSTONS MILLS , MA 02648
C/2 1 R HEY E- SffA Y
10
ENVIRONMENTAL SERVICES, INC,
0
S
0 20 40 50 P.O. BOX 627
T EAST FALMOUTH, IVIA 02536
AtVITA
TEL/FAX : 508-539-7966
SCALE: 1 "=20' DRAWN BY: CES DATE: MAY 21 , 2005
PROJECT#SD-748 FILENAME: SD748PP.DWG SHEET 1 OF I
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with'
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2 7un
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