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Home My WebLink About0274 SCHOOL STREET - Health S SchooIStreet .n $1Vlarstons Mills i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Mathieu Rebe110 use only the tab key to move your Name of Inspector cursor-do not Rebello Septic Inspections use the return Company Name key. 30 Norse Rd � Company Address South Dennis MA 02660 City/Town State Zip Code 774-722-0271 SI-14140 Telephone Number 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); 1 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 I.have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 04/25/19 Inspectors 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. 15insp.doc•rev.7262618 role 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k� ) 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. C3yrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): 15irsp.doc-rev.76=18 Title 5 Official Inspection Forth:Subswiacs Sewage Disposal Systern-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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: e t5insp.doc•rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owners Name information is required for every Marstons Mills MA 02648 04/25/2019 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 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 t5insp.doc-rev.7282018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St vi,v�w W Property Address Cooper Amster Owner Owners Name information is required for every Marstons Mills MA 02648 04/25/2019 page. Cityfrown State Zip Code Date of inspection C. Inspection Summary (cont.) 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® An portion of a cesspool or privy is within 50 feet of r Y P Po p y 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 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"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 t5irtsp.doc•rev.7/26/2018 Title 5 Official In spection Form:Subsurface Sewage Disposal System•FaAa 5 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. City/Town State Zip Code Date of Inspection 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 No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.rbc•rev.MM018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 or 18 f AN, Commonwealth of Massachusetts -, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b 1� 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2-3 Ii Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last Z ears usage 141 gpd 9 ( y 9 (gpd)): Detail: 2018-57,000 gallons 2017-46,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5msp.doc-rev.7@CM8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I, 274 School St Property Address Cooper Amster Owner Owners Name information is required for every Marstons Mills MA 02648 04/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes,discharges to: N/A Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/ADate Other(describe below): N/A 3. Pumping Records: P 9 s Source of information: at time of inspection Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7@6I2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owners Name information is required for every Marstons Mills MA 02648 04/25/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed(if known)and source of information: 2003 per board of health Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1'8"feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints tight,proper venting, no evidence of leakage. t5insp-doc-rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owners Name information is required for every Marstons Mills MA 02648 04/25/2019 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: $ feet Material of construction: ® concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. precast Sludge depth: 10" 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 12 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): septic tank was pumped after inspection. Inlet and outlet Tee's in good working condition. Liquid level is equal with outlet invert with no evidence of leakage t5insp.doc-rev.7r6=18 Tite 5 Official Inspection form Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. City/town State Zip Code Date of Inspedion D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forryc Subsurface Sevrage Disposal System•Page 11 of 18 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner owner's Name information is Marstons Mills MA 02648 04/25/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): ' The D-box appears to be in good condition with no sign of solids carryover.There is 1 inlet and 2 outlets with speed levelers present.The liquid level is equal with the outlet invert with no sign of backup or leakage tblimp.doc•rev.7J 16M18 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. Cityfrown State Zip Code Date of Inspection 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.): N/A *If pumps or alarms are not in working orders stem is a conditional ass. P P 9 i Y P 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located,explain why: N/A Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 I Commonwealth of Massachusetts F Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 ry 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25l2019 page. CityiTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): 2-500 gal. leach chambers with stone. Soil and stone found dry, no signs of hyrdaulic failure or unusual vegetation. Depth to cover 1'top of pit 34"liquid level 1"bottom 60" below grade. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer NIA Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NIA t5msp.doc•rev.llMMS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 14 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 Cityfrown 04/25/2019 page. State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5 ruo.Cac-rev-7126l2018 Title 5 Official tnspectlon Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,- p Subsurface Sewage Disposal System Form-No t of for Voluntary Assessments /r 274 School St Property Address Cooper Amster Owner owner's Name information is required for every Marstons Mills MA 02648 04/25/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 r� drawing attached separately 3�}- t A 0 0 Fro1� 1n/ t SLkoo l S Al - , t'b Bl - �3 AI- '9'9 ba- 4 a 3 S3 B3 - 44 '1 t5insp,doe-rev.MEWS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts 1a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 274 School St Property Address Cooper Amster Owner Owners Name information is required for every Marstons Mills MA 02648 04/25/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10'+ 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: 11/15/03 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 shows 120"with no groundwater encountered. Bottom of SAS is 60"below grade giving 5'+of seperation Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doc•rev.7/28/2018 TNe 5 Official 1 nspectian Form:Subsurface Sewage DisPosal System•Page 17 of 18 l r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 274 School St Property Address Cooper Amster Owner Owner's Name information is required for every Marstons Mills MA 02648 04/25J2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/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 5insp.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments +e. 274 School Street 4` Property Address Hillary Threlkeld Owner Owner's Name information is s required for every Marstons Mills Ma 02648 12-17-15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, J use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. Excavation Company r� Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority CR6& )ff' 12-17-15 Inspe or's Signature f 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. /yste age 1 of 17t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) .❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M , 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 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 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 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 331.8 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. CityTTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gp ))� Detail: 82,000gallons 2014-2015 Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is Marstons Mills Ma 02648 12-17-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of aH components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'8" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 5" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _ W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 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 31" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is not in need of pumping at this time. 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-box is in working order with no sign of back up or carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallon g ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 L f Commonwealth of Massachusetts M - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is Marstons Mills Ma 02648 12-17-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 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 building. Check one of the boxes below: Z hand-sketch in the area below drawing attached separately A L sc1� o(r go 0 t9l t l' (Dw 0 E z zs az- yz b3 L) cD t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 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: No Gw 120" 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: 11-15-03 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: Plan on file with BOH 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 274 School Street Property Address Hillary Threlkeld Owner Owner's Name information is required for every Marstons Mills Ma 02648 12-17-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E 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 C V) . .... .. .... -... ::. ::: ..:::.' 1 .... ...: ... .-:- - .... ...:.... ... ......: ...- .. ... ..:.::: ........... . ...... ...... .: : :. C...''. ainw alth o f a s Ch sd .. _ i m i Subsurface Sewage Dasposat System F ' . tat for Voluntary' 4ssessments. _Darns Porter : Property;Addre,s . :, School Sf; . Owner Owner s Name mforrnahon:'s Marstoris [if Ma 02648 1211112013 required for every .. ... page CrtyRawn State. Zip Code Dates of Inspection ... Inspection results must tte:`subm,titeci on this form Inspection forms:may rant be tittered:in any way.Pleasa see toiva,pI te.riess"ehetklist at"the end of the foettit. Important*When � nt r 6 lnfdr a�tic n flling,out forms :: on the computer, use"only the tab 1 Inspector key to move your .. cursor do not Sean M Jones. use the-return --- ke Name of Inspector y Capewide Enterprises rya Company Name 153 Camrt erd, . .': rem x:::.�::�.�:::.::::,::..�1::p::II::,:I.::..::.::..::..::.:....�.�:4.:.:.:.:,.�.: Mash ee Ma Q264, �.__.m._._p._............ .............................:................ . ...... .....:.:..... Gity(rown : State Zrp Code 508-_ 77 8877 _SI 4522:' Telephone hiumber :' ::: License Number . _ _ E'i'�t$f canoe . i I certlfy;that I.;have per ..... y inspected thesewage disposal system at this address and that the Inforrriatlon reported:below Is true;accurate and complete as of tte time of the inspection The inspection "was perforrnetl based`on my training,arfd experience in ttie proper function and:rnalritenance of on slfe ;,sewage disposal systems I aM a DEP'approved system inspector pua°suani to Section 95 340 of T'tle.5;(310 CMIZ l5a000j The system �. Passes ❑1:1 Candltronally Passes;! ❑ I=ails Needs Further Evaluation by.the Locai Approvi.ing Authority _:. P.. i .... .. .: ..- ... I. :::' -.....:.. ::::: :::: ::: y _ .. :. '.: 12/1112(j13 r I ... .. . ... -.__ ... -. :. �:ii _... ..._ -. .. ..! .. Inspectors Signature: z Qate f :. ._.. . ._ . . . __ ..... ... .. . __ _ . .. V: T1*system inspector stall subrrtlt a copy of this Inspection report to the ApprqNvmg;A' the''ty(...a of Health,or DEP}within30 days of completing;this mspectron If the systemas a shared spstemc r has a design ftow;o#10, gptl;or greater;,the Inspector and the"system own;tJ6 r shall sul ilt theme :: report to the appropriate regional oJce of the DEP Tl e.ariginal should be se the sXst m owner and copies"sent.to the buyer, i#applicable,aria-the approving"authority. �'°1 '4**&This repot only ic9escribes conditions at the't'me of inspection artd unider the conditions of:sae. at;that titre "Chia inspection does not address hors the.system,W u1 pestorrra in:the$afore uridet : :! the s;rtme:or d1 Went conditions of'use :: }sins 73; Title S'oificial InOed#Forme;Subsurface'Sewage,II.Dispasal System. Page 1:of,::.!I: YT, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 274 School St is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 500 gallon leach chambers.The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityfrown 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): J C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. City,?own State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 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 and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was.the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd 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 Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 _ page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 E No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2012—74,000G &2011 —66,000G Sump pump? ❑ Yes ® No Last date of occupancy: vacant Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Janis Porter Property Address 274 School St. Owner Owner's Name information is Marstons Mills Ma 02648 12/11/2013 required for every page. City.rrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system repaired 12/18/2003 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joint were ok, no leaks, vented through the roof Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: � 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 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 3" Y Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityrrown State Zip Code Date of Inspection D., System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert, no sign of past hydraulic overloading 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityrrown 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.): no lush vegetation, no signs of past failure 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 cesspool o f I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 0 ..... .... ..... ..._... _ ._ ...... .._....... _ __ _ _. . __ _ ..__. ___ __ ..... ... ......... .. ......._. . . .....:r.. .._. _.__ . ........ . _...... .._ .... .......... .... ... _ _. . _ _ . . _ _ - .. ... .. . . .. .. .. ... .... ... C® , 0lnwo o l�lassachus� a - p � l �i 1 Subsurface Sewage:[?i$#0 at Syster�i FbMa Not,faW I ntary Assessments ... .. _. Jams Porter . .. .. .. :: . .. Pro a Address .__., p d1. .: 274 School St ;: Owner _ ..; Owner s Name �nformatton is Marstons Mt{IS Ma' t}264$:; 12t11[2013 eeg.ir q for;every _.. page CitylTawri; 1 . State Zip Code Date af!tnspe tion system; f rm fi. n {cant } Sketch Of Sewage:Llts osal Sysfem Provide a view of the sewage dtspasai system,,.includng ties to p at least two:permanent reference landmarks or benchmarks. Locate ali WO lt:wt, in 140 feet: Locate where,publc water.supply enters;the bi"iidtng. Check cue of the:boxes below;. :: ® hand sketch tn`the ar`ea,below ❑. dIa'.I.g attached separately 'y :' : .. _:: .. .. 1k :: t : ?. tip 5 .. : : �: ' ........I. . . - __._....._ ... ..._ ... .. _.. _. .... .. _... _..... ... _. . .... .. __.......__ ........ .......... ........ ...I...__ jI`Z' 2 �, �; t 2' � 3 '' � r f5is 3113 i af'17 7.... Title 5 Off cial,Inspect on Form SubsuHace Sewage D(spasal'' ' ' *Page 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Janis Porter Property Address 274 School St. Owner Owner's Name information is Marstons Mills Ma 02648 12/11/2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet+ Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Janis Porter Property Address 274 School St. Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2013 page. Cityrrown State Zip Code Date of Inspection E. IReport 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 TOWN OF BARNSTABLE � i LOCATION � y SEWAGE # �� dY1a ASSESSOR'S MAP & LO VILLAG4,41 ET INSTALLER'S NAME&PHONE NO.' — ` SEPTIC TANK CAPACITY-- �� LEACHING FACILITY: (type) . �' - (size) NO.OF BEDROOMS � � 5. , I • BUII.D,ER OR OWNER �Qi f/�2�1 �1 � PERMUDATE: _COMPLIANCE DATE: I�r��—�� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 4 /cam 6,&.t, T/Nz, r f c RIFF"INJED COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFKTR9 ' 2003 DEPARTMENT OF ENVIRONMENTAL PR 'ILL RNSTABLE W DEPT. FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW DISPOSAL SYSTEM FORM pp A CERTIFICATION Property Address: era d Way Marston Mills. MA 02648 Owner's Name: Trudy Diamond Owner's Address: Date of Inspection: September 19, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 046 Mailing Address: P.O. Box 49 Parcel: 079 Osterville,MA 02655-0049 Lot.413 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes N e�slfurther Evaluation by the Local Approving Authority ✓ Fail Inspector's Signature: Date: September 24, 2003 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Emerald Way Marstons Mills. MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Emerald Way Marstons Mills, MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Emerald Way Marstons Mills. MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`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 ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 Emerald Way Marstons Mills, MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ 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(3)(b)). 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 8 Emerald Way Marston Mills, MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection (yes or no): No If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Jun. 15176-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 Emerald Way Marston Mills, MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 BUH,DING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of sum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid was even with the outlet invert. There did not appear to be any sign of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 Emerald Way Marston Mills, MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 Emerald Way Marstons Mills. MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'- 1000ga1. 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.): There was 6'ofliguid in the pit. Liquid was up to inlet pipe. The scum line was above the pipe: There appeared to be signs of hydraulic failure. The cover was 20"below grade. The bottom to grade was 9. CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 Emerold Way Marstors Mills, MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A a � c� 0 B C>L O �. yo 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 Emerald Way Marstons Mills, MA Owner: Trudy Diamond Date of Inspection: September 19, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showingapproximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and failed of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 • COMMONWEALTH OF MASSACHUSET'I'S Z , EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION M �y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2-74 gc�tooU( St-, RECEIVE® o rs d dn.S iUS l Owner's Name: tiyo:r) APR 19 2001 Owner's Address: TOWN OF BARNSTABLE Date of Inspection: [[ Q 1 HEALTH DEPT. Name of Inspector: (please print) ?e-f-er I MCGvV+el Company Namc: `fl1a,�h.ep_r.'„ta Wur1-ts Mailing Address: .'z3 VRe, i-10 11 ula t&A �o�-e t-rrla��e 0264'q' Telephone Number: 13 CERTIFICATION STATEMENT I certify that 1 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passe$ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �'' Date: tl jai 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. i Notes and Continents ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS.;. SUBSURFACE SEWAGE01SPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: 0-74 Sc ka-c) Owner: Date of Inspection: i��) i Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NlA G One or more system components as describe in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replac went or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years of •or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfil O twk faihue is imminent. existingtank is replaced with a com 1 in s tic as. v�d System will pass inspection if the p p y g eP appro by flte Board of Health. *A metal septic tank will pass inspection if it is s cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is vailable. i ND explain: , Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or un ven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s are replaced obstruction is moved distribution x is leveW.or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of ealth): broken pipe(s)are replaced J obstruction is removed i. ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 274 Scb\,p( S1-. Owner• —T-T-.o r-%aS W'cam 4-- Date of Inspection: alit 0 I C. Further Evaluation is Required by the Board of Health: �rA Conditions exist which require further evaluation by the Board f Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accor lance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect put lic 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 vegetate wetland or a salt marsh N/ 2. System will fail unless the Board of Health(and Public Wat r Supplier,if any)determines that the system is functioning in a manner that protects the public healt ,safety and environment: _ The system has a septic tank and soil absorption system(S S)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 with n a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is wit 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less han 100 feet but 50 feet or more from a private water supply well**.Method used to determine distanc **This system passes if the well water analysis,performed at a EP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well s free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must:be atta hed to this form. 3. Other: 3 • Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGEMSPOSAL SYSTEM INSPECTION,FORM { PART A ' CERTIFICATION(continued) Property Address: 2 74 Sao( 5t1 mars Owner: —T_kV nos (/vc.L1}- Date of Inspection:_q-1 ,[ 0 1 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: — Yes No Y. Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool F _ _.2L Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool �C Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ g 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. _2�- 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 coMrm bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or1m than 5 Phi provided that no other failure criteria are triggered.A copy of the analysis mast be.attached to this form.] NU (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303;1herefore the system fails.The system owner should contact the Board of ' Health to determine what will be necessary to connect 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• You must indicate either"yes"or"no"to each of-the fc llowing: (The following criteria apply to large systems in additic n to the criteria above) yes no — _ the system is within 400 feet of a surface dr' ' g 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 are (Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well . Ifyou have answered"yes"to any question in Section E e system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The wner 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. 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2 74 5c. \o cr j Owner:.'TFa r►as wu-�--. Date of Inspection: +1 b1 lit j Check if the following have been done.You must indicate"yes"or"no"as to each of the following: j Yes No Pumping information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? — Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? Were all system components,exl�g 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: Yes no X Existing information.For example,a plan at the Board of Health. G ( _ 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(3)(b)] i 5 Page 6 of 11 OFFICIAL INSPECTION FORM r NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION Property Address: Z'74 Owner• _TKay1_k �l IN aT}- Date of Inspection: s}-1 it ,o` FLOW CONDITIONS RESIDENTIAL may( Number of bedrooms(design):No r"' Number of bedrooms(actual): `Z- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: "L Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):lU_o [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Al a Water meter readings,if available(last 2 years usage(gpd)): c n.e f�-V�i W Sump pump l.� es or no): (YLw ) Last date of occupancy: �. COMMERCIAL/INDUSTRIAL Type of establishment: A 1A Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.). Grease trap present(yes or no):— Industrial waste holding tank present(yes or no Non-sanitary waste discharged to the Title 5 sys em(yes or no _ Water meter readings,if available: Last date of occupancy/user • , k � E OTHER(describe): � 7 Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yells or no): /V(3 If yes,volume pumped:_gallons--How-was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _�4,Septic tank,distcihuiiej_j)aX,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 274- -Sc-kocil Owner:-T-kc51Mw wa,-j Date of Inspection: +1 tl 1 6% p BUILDING SEWER(locate on site plan) Depth below grade: I Materials of constructiom._cast iron _2�_40 PVC_other(explain): Distance from private water supply well or suction line: 7 -7T Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:.(locate on site plan) Depth below grade: 10 Material of construction: concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of ` certificate) Dimensions: 4- l O X 8 6 x S=-'7 " F Sludge depth: ('7 t1 Distance from top of sludge to bottom of outlet tee or baffle: 7,3" Scum thickness: I " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or b26C-e : How were dimensions determined: pua sar"'I., Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evi ence of leakage,etc.): d ` �- GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: i Scum thickness: Distance from top of scum to top of outlet tee orb ffle: Distance from bottom of scum to bottom of outlet ce or baffle: Date of last pumping: Comments(on pumping recommendations,inlet ar I outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc. : 7 f f Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEA.INFORMATION(continued) Property Address: 274 Sc 601 St Nears1.o s Mj1l _� Owner: Wcz,I,- Date of Inspection: TIGHT or HOLDING TANK: (tank must a pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order( es or no): Date of last pumping: Comments(condition of alarm and float switche ,etc.): tjiA DISTRIBUTION BOX: 100114(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution outlet cquA any evidence of solids carryover,any evidence of leakage into or out of box,etc.): u1� PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condit on of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27i St- Vkv Owner•'-em\as W-Z'*- Date of Inspection: 4-{N 1 y 1 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T 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.): t Lla V:J N d 544115 0%F s yr NlA 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 or no): Comments(note condition of soil,signs of hydraulic failure,level.of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraul failure,level of ponding,condition of vegetation,etc.): 9 � 0 Page 10 of 1 I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE01SPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2;7+ Sc-h-dA S+-- Owner• T�a M(.% W y�}- Date of Inspection: 64 tl C SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. i i i i i i % Abutting properties on town water S.A.S. ' Septic i Tank i A 2E:A li Exist. 2 Bedroom r I � House 0o OFFSET TIES Al 12 .0 A2 18.0 , B \w A3 32.0' , a F---� ————————— B1 23.0 B2 27.0' 8 93 3 .5' � - ; `�\ �� \ i . Well Parking I' SCHOOL S TREE T 10 E Page 11 of 11 z OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 274 Sc6 c j Si-,, McN)k-crL4 M kh Owner: Tlk"n^a' Date of Inspection: 6 j it I d SITE EXAM Slope -Z`to Surface water Nvtie. Check cellar O[.< Shallow wells A107t.-e Estimated depth to ground water 1.5-4 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: QfIZ q+-4G L You must describe how you established the high ground water elevation: 02• C9at exrY" a} S i Le �r t-e.J go _w/ CA ' si L"�an� i f k 11 �Z7 jC&.Tlwl : / 07— -5113 SE\"&CaE PERMIT UO. . �/ILLpGE '• /Y�i�� i�du � �i�.� S IMSTQLLER S U&& AE l�DDRESS ®tL!/y 'BUILDER Q W"E ADDRESS pCQT-E -PER VT 15SUED •_ s �! �� — D ATE- COMPLI &MCE ISSUED : — — — 1 o � _ cy w FRoA)-r f�A)°%j o V'SE L` THE COMMONWEALTH OF MASSACHUSETTS �AAP �T\D BOARD HEALTH r hiCEL .--------OF........ gF .....-..-................... ........- LOT Dj) Lion -for 43itipoottl Works Tontrurtion Vrrui t Alicatio i y'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: U%R t- ._. • / o mT,olyti�}t�Address or Lot No. -•--•-•-----------------......----••............................................. ._..-•--------`----•---•-•--•---•...__..._...•----•.......•---••-•-•------•-----••---•-------••--- O n Address a - . ,F---------------------------------- ----------------------- Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling Expansion Attic ( ✓f Garbage Grinder ft No. of Bedrooms.._. -______________.................. aOther—Type of Building ............................ No. of persons---------------------------- Showers (I ) — Cafeteria (00) a Other fixtures ..... d ------------------ --------------------•-------------...------•---------------- w Design Flow__ _ _____________________________gallons per person per day. Total daily flow......Z_a.d......-.-•-•--._.-_.___gallons. WSeptic Tank L Liquid capacity/U.d gallons Length................ Width............---- Diameter-------.-------- Depth_-________--. x Disposal Trench—No. ____________________ Width___________ _ ._ Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No....l.............. Diameter_. _0-__ Depth below inlet.................... Total leaching area-----------------.sc. ftAll z Other Distribution box ( ) Dosing tank ( ) 6 �G - =;�j—-7 y- lqo'f Vet aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit..................... Depth to ground water--_____.-____.____-_-_.- �14 Test Pit No. 2................minutes per inch De th of Test Pit._______________.___ Depth to ground water__-__._..___________ -. ---------- Description of Soil------ ® -- 1 -------� .{'-. - O ---------------------- x _...----..._Z.-=--1--k---- _.._. - -- --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- v f.. w U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------.. -------•----------------------------•--•--------------------_-----------:__-----•------•-------•-------------••--•--------------•---------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by thesboard of health. 1 �j �°- Signe ^'�_________ _••-___/-•----��._ 6�E � v Date Application Approved BY ��"L ✓1 �� 1 S---' Date Application Disapproved for the following reasons:................................................................................................................ -------------•-------._..__._....----....-------••----------------------•---•-•--------•----•-..-•--•----...-----•-•-----•--•----.._._.-----•-----•-••----•-----•--------------•-•-----------•----••••••- Date '� Permit No. Issued - ...-••- Date 02s g //� � i THE COMMONWEALTH OF MASSACHUSETTS BOARDF HEALTH _....._1_6.1.1..--- ..OF......... �'� ... . -------------------------------------------- Apphration -fur IMBpuuttl Workii Tuufitrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: M T� 4L1) d r 4076 `�.3 ----------------------------------------------------------------=-------••--•............-•-••-... ..........•-----•-•--••••-----••-•--•--•-••-•••---•••••••-••---•--••----------•-•---.......-•--•- ` •I.oa'atla Address or Lot No. f.. Owner Address W Installer Address Type of Building Size Lot............................Sq. feet Dwelling A No. of Bedrooms-----.-7-___________________________-----Expansion Attic Garbage Grinder ( ,c)J 114 Other—Type of Building -------------•.............. No. of persons_---------_---------------- Showers Cafeteria al Other fixtures --------------------------------- W Design Flow-----r �............................gallons per person per day. Total daily flow....... . . -_---__-_---.-_----.gallons. WSeptic "Dank Liquid capacity/q U_gallons Len-th---------------- Width------------._.. Diameter__-__-.....___-_ Depth_.___--.._...- x Disposal Trench—No. .................... Width------------- .A Total Length------------_------ Total leaching area-------------.------sq. ft. Seepage Pit No-----I.............. Diameter..Z41 .r�__�Depth below inlet.................... Total leaching area.......-._._.•_...sq. ft. z Other Distribution box ( ) Dosing tank ( ) a h - S-;�1' -7{ r•Alft7 1 eI ' , Percolationsuits Test Pit No. I----------------minutes per inch Depth of Test Pit____________________ Depth to around water-----------------....... f14 Test Pit No. 2................minutes per inch ee th of Test Pit-------------------- Depth to ground water__._-..__-_-__-...._-... O ---------- A +� = --•--.......- --------------- --- _ ` Description of Soil------- .. y '� k'-- x ! -- W U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,issued by the,board of 114ralth. _ Signe }--• - I Date Application Approved By.. �= r. �'-�•-• •-----�17-- !'t : ...................... ----- Date Application Disapproved for the following reasons:-_--------------------- -------------------------------------_---------------------------------------- ................•--•-.....---•-•---------••-...........-------•----•--...-•-•---•-••••••--•-------•----...---------..--•-......--•-•-•-•••-•----•--••--•-----------------------------.......------_.•--- Date Permit No......................................................... Issued......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 101rrtif iratr of VTOntliliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( /<Or Repaired ( ) by. .. ----------------- r Installer/� •---- !/ i1 at---" /``�/_.-ya...... -1, C ,� l�c --- - ---g,cl�� --- L�:,--`:'=------------------•------------- ---- ------------ - has been installed in accordance with the provisions` of Arti-� XI of_The State Sanitary Code as described in the application for Disposal Works Construction Permit No.--- ..._�?. .�7............ dated..__._ .-.�5...".7G............. THE ISSUANCE OF THIS CERTIRCATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ....DATE__.. / r Inspector . .................. THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH . j ��_ ............ t! s......OF........... r >: :+�-'I. . '..................• J No. 3_.. FEE----- -----.----- Bisputitti urk� tuutrurtivatdrrunt Permissionis hereby granted....................................................----------------------------------------------••-- =!` to Construct ( �f"or,Repair ( fan Individual S 'A Di sa System } at No. l,1 �/f 1 LI J a _ • �s�-1 Street •� ti as shown on the application for Disposal Works Construction Permit' o......ZI..,::.___. Dated...................t } ... .. -------------------- 7/ Board of Health DATE .................................................. JJJ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i LOCATION d7— 5E\N&CaE PERMIT 1JO. -ram-- , AL�, — VILLAGE IWSTQLLER•5 UNME ADDRESS e BUILDER Q &V AE/,4 DD A RESS DILATE PERNA17 155UED D ATE COKAPL1 &MCE ISSUED : 4 L ei7` 9! 6 - 23 J I i� I I � 41A.. N = : 3q �= y. - r 41 4 ,�. 5 as 1-7 l C—M Ei2AlT..) 4o' �''/ `"�'', LoLAT'1 aJ ' M A�r�►JS M�u.5 '�aA La A.0 VA M Co/1/-7 TE L ,F 1 � Lvt Q is r � / Ce,07-iF'1/ TEAT' 7WC 1co4)vD,477LVJ �.A► b. COL)QT PLAQ sNou>N NE�Eo.V Cort>P��S w� r�-� - r-r/[' Zb•V>�� -44 WS ar TNC $A xT EZ � iJy C I tJC 7'ou%-t) of= f.f,�i�N.5TA3Lc`�. Q"ElarS*rC-e—.'- -A ,J )ejcls I r'•- OS�iZ.✓I u..G - MASS i ��U� er o t4 SC�vo TOWN OF BARNSTABLE C— L�CATION SEWAGE # 03 —II�602 VILLAGE ILd I1 izzs ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)p�� ,ftrX5 (size) NO.OF BEDROOMS a D�PDom s. ,i BUILDER OR OWNER ZRL191 01~S , ERMITDATE: ! Q I7-es3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater'Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6 331 sko. c Fee i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21pprication for ;Bigozal 6potem (Construction Permit Application for a Permit to Con tract( )Repair(V)Upgrade(,5� )A an on ) -Comp to System El Individual Components Location Address or Lot No. r L• L1�f i �(�j (3 Owner's Name,Address and Tel.No. G°fC� r` �i RC14 E JC "010 t/6 Assessor's Map/Parcel MA(��Ji�N> �..iLLS O - C In taller's Name,Address,and Tel.No. `RO- 450 Designer's Name,Address and Tel.No. �/S�G. "veli-�✓ 9AXAW ftgvl I& e P CA tyl-K5 85 ITLJ-5" SRC-Im4l z Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S.- —�ccJ� �L l'lu,�►bvt� Description of Soil 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 to place the system in operation until a Certifi- cate of Compliance has been is by t is d of H th. Si ed Date .t Application Approved b Date v 3 Application Disapproved for the following reasons Permit No. ��c) Date Issued R r �'., ,o• O��' "'"Gd?i3„s .,« ;M,....... Fee �o ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ i�� Yes PUBLIC HEAL H DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for Migo�al *p5tem Construction VernYit A lication for a Permit to Construct )Repair \pp ( ) p (�)Upgrade( )Abandon( ) ❑Complete System ElIndividual Components f .. C Location Address or Lot No. $ �� [° �(� `� Owner's Name,Address,andiTel.No. Im„a�po 1— r ,' a Assessor's Map/Parcel 0TA010Mb ��✓i��`/S I �L�5 rTq 6 o79 Installer's Name,Address,and Tel.No. t�.a�„ 5(L� Designer's Name,Address and Tel.No. //Sf� u✓ t�E.S ail=I�N l�(fort� TT - a,0 t vP Grr' tnA(k K S M Iu S a 3 066qhoe_w(u lA RcsTt Type of Building: ; Dwelling No.of Bedrooms Lot Size ' sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �fa00 Type of S.A.S. ." - Description of Soil Nature of Repairs or Alterations(Answer when applicable)!.3 S if Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system to 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 issu by this B,6ad of Health. Si ed Date /-L Application Approved b Date 1 ,;�/o A,3 Application Disapproved for the following reasons l` Permit No. ry pQ ,� ^ L9d Date Issued �0 d THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS Certificate of Compliance 4 . , THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by _ , at S( r .A C rA Irl Li 11 P NI. nA, II 1 has been constructed in accordance .� ,�o-• -and yam; . with the provisions of Title 5 the for Disposal System Construction Permit No. 2&3—W dated I _,�, l"I P? Installer Designer The issuance of this permit shall not be construed as a guarantee that the syst`e'mmwill function as' esigned. Date ' f d;; Inspector ,.J q^ ' X j— ---- No. //A./ �"✓P � --------------------Fee �- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwt!6pozal *potem Construction Permit Permission is hereby -anted to Construct pRepair U grade(/ Aband. l ) 7 J System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to`;` comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust b'completed within three years of the date of a it. Date: / d e Approved by THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA �Mr�c's�crnsC�,��15 . • � . t - r fWY)3t--Il 114 6 .-�/ . j . 4 j _ i _ } i i 1 i 4 ' ) I ('//may. .. .._.__._...�._......._.._.._._.__." _ � f f, �yf r f r ` LEGEND N55049'46"E 9g PROPOSED CONTOUR C 129.24, a -� 99 PROPOSED SPOT GRADE — / O 110_ EXISTING CONTOUR 110 EXISTING SPOT GRADE 00c;QO� n 3 \ TEST PIT `11 U1 \\\ ` \ \\ \ \ —W EXISTING WATER SERVICE rn EXISTING S.A.S. School Street \ \r'O \\ TO BE REMOVED _ EXISTING TREE Asa Lei s Rd (SEE NOTE 12) Locus ` rn I NI-1 \\ \� 'ems ,\\�\ �``_�2O EX15TING TANK it) (f0 REMAIN) LOCUS MAP For illustration only) �� \ \ \\\ \ \� COVER ELEV. = 101 .44 INV.(OUT) EL: 100. 1 - '"`~" --�-�- AT �p,� GENERAL NOTES ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 1� BASIN . J� rn BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE N I"0 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: x W `� 310 CMR 15.221(7) GENERAL CONSTRUCTION REQUIREMENTS: F.l O � D N �� SIZED _ W 1) A 2' variance to maximum cover requirement of 3', for IpGc , N a maximum cover of 5' over a portion of the S.A.S. 5TRIPOUT 2 k k 1 s STpC f Q� �� OF tijgS 3. PRIOR E SEWAGE INSPECT INSPECTION AND APPROVAM BY THE BOARD OFCHEALTHAL SYSTE SHALL NOT BE BAD TO AND THE TH (See note 12) 1 1 FENCE O ��P 9�y DESIGN ENGINEER. m `— = o= RICHARD G� 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING TP-1 AFC 1 0 3" ENOG N ER BEFORE CONS TRUUCTIONEON ACONTINUESREPORTED TO THE DESIGN DECK HOOD 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. x POOL AREA o. 35031 �k XI STING '" o �� 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF v p�CKt7 BEDROOM THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF rno 1 v ONCE k �� H0USE(No.B) S� HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. CO T.O.F. = 103.I/ 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. BENCHMARK: rn 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 100' OF THE S.A.S. MAG. NAIL SET / N 9. SEPTIC SYSTEM COMPONENTS SHALL BE INSTALLED AS DESCRIBED EL: 100.00' v xt�t2 1 -� IN 310 CMR 15.000 SUBPART C. (ASSUMED DATUM) �+ `a�Q�� 10. ALL AREAS DISTURBED DURING CONSTRUCTION ARE TO BE RESTORED rn pF *S AS AGREED UPON BY OWNER AND CONTRACTOR. rn \ Q�� s9l 11. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE AP N' 04 6 0 7 9 z `� PETER T. CTHE ONSTRUCTION,OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CATCH 6 STO n MCENTEE 12. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS BASIN I (LOT 413) "°�� , CK'°iDF ONCE rn CIVIL IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. r'n Cep X No. 35109 AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). AREA = 20,45G± 5F ONh ENS\ \� % CRUSHED STONE 105.00, - 57001'55°W PROPOSED SEPTIC SYSTEM UPGRADE r v� 8 EMERALD LANE, MARSTONS MILLS, MA CATCH Prepared for: Trudie Diamond, 8 Emerald Lanee, Marstons Mills, MA BASIN OF PAV MENT Engineering by: Surveying by: SCALE DRAWN JOB. NO. Engineering Works HOOD SURVEY GROUP 1"=20' P.T.M. 91—03 SCHOOL STREET _ 23 Deer Hollow Road 18 Route 6A Forestdole, MA 02644 Sandwich, MA 02563 DATE - CHECKED SHEET NO. (508) 477-5313 (508) 888-1090 11/15/03 P.T.M. 1 of 2 1 - y NOTE: TO PREVENT BREAKOUT, THE PROPOSED F.G. EL: t03t VENT FINISH GRADE SHALL NOT 8E < EL100.2 i `F.G. EL: 102-105t TOP OF FOUNDATION FOR A DISTANCE OF 15' AROUND THE EXISTING EXISTING PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S.A.S. mmm INSTALL RISERS W/COVERS OVER INLET & OUTLET TO WITHIN 6" OF FINISH GRADE 2-500 GALLON LEACHING CHAMBERS INSTALL RISER OVER ONE CHAMBER IN SERIES WITH STONE-ALL SIDES (MIN.) WITH HEAVY DUTY FRAME & L =10` COVER SET TO FINISH GRADE. L -13 s' 4" SCH 40 PVC - (MAX) 4" SCH 40 PVC ...-2" LAYER OF 1/8^ TO 1/2" 0 S= 1% (MIN.) s ®a O ®® DOUBLE WASHED STONE a. 0 S= 1% (MIN.) EXISTING E7. XISTING 1000 GAL. 2' EFF. DEPTHT aaa®a®® �- v :a::: SEPTIC TANK I ®®®® PROPOSED INV.EL.=99.83 4' S.2' 4' DOUBLE WAS INV.EL.=100.10t INV.EL.=100.00` D-BOX DOUBLE WASHED EFFECTIVE WIDTH = 13.2' STONE INSTALL INLET & OUTLET TEES (EXISTING) GAS BAFFLE TO BE INSTALLED ON INV. ELEV.=99.70 OUTLET TEE AS MANUFACTURED BY TUF-TITE, ZABEL, OR EQUAL D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE TOP CONC. ELEV.=100.5 —BREAKOUT ELEV.=100.2 ON A MECHANICALLY COMPACTED SIX INCH CRUSHED INV. ELEV.=99.70 ®�®H® STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2):. ®®10��®®a®® BOTTOM ELEV.=97.70 3' 2 x 8.5' = 17.0' 3' 5' ABOVE MAX. SEASONAL SEPTIC SYSTEM PROFILE HIGHIN.GROUNDWATER ELEVATION EFFECTIVE LENGTH = 23' N.T.S. NO G.W. ENCOUNTERED LEACHING SYSTEM SECTION Of tilgss (3) 5~ DIA.OUTLETS BOTTOM OF TP, EL: 89.3(TP-1) 16' o PETER T. 1I-- s'S `I -- 2 f McENTEE DESIGN CRITERIA o No,CIVIL109 N 1s.s^ Q 1. RfGIS1E�� `� 6„ $ NUMBER OF BEDROOMS: 3 BEDROOMS SfflNh 2• SOIL TYPE: CLASS I DESIGN PERCOLATION RATE: 2 MIN./IN. D--BOX SOIL LOG , DAILY FLOW: 330 G.P.D. t\\ DESIGN FLOW: 330 G.P.D. DATE: OCTOBER 16, 2003 I GARBAGE GRINDER: NO SOIL EVALUATOR: PETER McENTEE ( i LEACHING AREA REQUIRED:IR : 330 = 445.9 S.F. I ( ) INVERT ®®®® ® ®®®® 74 ®®®®®®®®®®® Elev. TP-1 Depth Elev. ®®�®®®®®®�® 39^ -0" TP-2 Depth - I N I �' SEPTIC TANK PROVIDED: 1000 GALLON (EXISTING) 101.3 0" 105.0 o~ 24" ®�®®®®®®®®® FILL A LOAMY SAND I I t0YR 3/3 •� 96.6 A SANDY LOAM ss toa.s B s" L--- USE 2-500 GALLON LEACHING CHAMBERS IN "SERIES 102" 10YR 3/3 EC ON � LOAMY SAND 24,'�1 96.3 60" 10YR 5/6 B LOAMY SAND 103.0 c 24" SIDEWALL AREA: 2(13.2' + 23,0') X 2 = 144.8 S.F. 1OYR 5/6 94.3 841. W BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F. 4" KNOCKOUT c r' TOTAL AREA: 448.4 S.F. 20" Dw. covea CP. /EX15TING r / MED. Z BEDROO SAND / M i KNocKour O 4" KNOCKOUT 82"- - zsYs/81 f,HOU5E(No.B)1,,- DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. MED. SAND 2.5Y 6/8 T.O.F. 103.J, q PROPOSED SEPTIC SYSTEM UPGRADE 4" KNOCKOUT ._ w 8 EMERALD .LANE, MARSTONS MILLS, MA 95.0 120"' $9.3 144" d p PLAN Prepared for: Trudie Diamond, 8 Emerald Lanee, Marstons Mills, MA 500 GALLON CAPACITY, H-20 LOADING PERC'RATE: 2 MIN/IN. ("C° HORIZON) :: Surveying by: SCALE DRAWN JOB. NO. NO GROUNDWATER ,ENCOUNTERED,-. ' y [EnginseringWorkr neering by: HOOD SURVEY GROUP P.T.M. 91-035 ,, ' A:S: LAYOUT ',M ' NT.s.: CHAMBERS S eer Hollow Road 18 Route 6AN.., _ stdale, MA",,02644 - Sandwich, MA 02563 DATE CHECKED SHEET NO. ' (508) 477-s313 (sos) e8s-1090 1,1/15/03 P.T.M. 2 o f 2 k C. Ha