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Home My WebLink About0027 SHAMMAS LANE - Health 27 Shammas Lane Marstons.Mills P C" in V a ,kt I I I i �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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 �I on the computer, use only the tab 1. Inspector: ` key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B&B Excavation �y Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City(rown State Zip Code (508)477-0653 S14595 Telephone Number License Number B. Certification y I certify that I have personally inspected the sewage disposal system at this add es�s and tha`the information reported below is true, accurate and complete as of the time of the i ection. Tie'inse tion was performed based on my training and experience in the proper function and m intenanc4f onAle sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340A'--li Title 5(310 CMR 15.000). The system: ' Zit ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/27/14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ^^'' L10 Z II t5ins•3/13 Title 5 Official Inspection r ubsurface Sewage D P. Syst m•Page 1 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merolla Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump,Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merola Owner. Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *k 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•3113 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 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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 .�° 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 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 n/a 9 ( Y 9 (gP ))� Detail: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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 aA i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original to dwelling Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >20 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 1 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. Sludge depth: 6„ t5ins•3113 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 "t 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 . page. CitylTown 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 no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection septic tank appeared to be in good working,tees present no sign of back up 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 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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 appears to be in good working order no sign of deteration or carryover. 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 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2)3x32 ❑ 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 in working order no sign of hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 page. Cityfrown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�' 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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: ® hand-sketch in the area below ❑ drawing attached separately A AI = �3 63 P t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 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: >11 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 9 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Shammas Ln. Property Address Frank&Tara Merola Owner Owner's Name information is required for every Marston Mills Ma. 02648 6/27/14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked ® 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 I l ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000. Inspection forms may not be altered in any way. A. Certification v Y - /C, �— Important: When filling out 1. Property Information: forms on the computer,use 27 Shammas Lane only the tab key Property Address to move your Marcio Coelho cursor-do not use the return Owner's Name key. 27 Shammas Lane Owner's Address Marstons Mills MA 02632 .A&� City/Town State Zip Code ICI Date of Inspection: 3/28/2006 Date 2. Inspector: Sean B. Skehill Name of Inspector Tomily Corp. 4 C mpany Name P�O. Box 959 Company Address North Falmouth MA 02556 z City/Town State Zip Code 5U8=563-5877 Telephone Number > 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 ❑ Fails ❑ Needs her Eval do by the Local Approving Authority 3/28/2006 Ins or's Signt ure 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. t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 27 Shammas Lane Property Address Marstons Mills MA 02632 City/Town State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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: Residence has finished basement with no additional bedrooms. Owner stated 3 residents reside here. Permit for basement was issued by Town of Barnstable. Space over garage contains no bedrooms-per owner 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: t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title, 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M ' A. Certification (cont.) 27 Shammas Lane Property Address Centerville MA 02632 Citylrown State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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 ❑ 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: 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 t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 27 Shammas Lane Property Address Centerville MA 02632 Cityrrown State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 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: t5insp2.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 27 Shammas Lane Property Address Centerville MA 02632 City/Town State ZipCode Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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 '/Z 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 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. t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 27 Shammas Lane Property Address Centerville MA 02632 Cityrrown State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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 ❑ Z the system is within 200 feet of a tributary to a surface drinking water supply ❑ Z 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. t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Checklist 27 Shammas Lane Property Address Centerville MA 02632 Cityrrown State Zip Code Marcio Coelho 3/28/2006 Owners Name Date of Inspection 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? Z ❑ 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(3)(b)] t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 27 Shammus Lane Property Address Centerville MA 02632 Cityrrown State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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): 330gpd Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 1122gpd +- 9 ( Y 9 (gpd)) Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Last date of occupancy/use: N/A Date Other(describe): t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 27 Shammus Lane Property Address Centerville MA 02632 City/Town State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 5 yrs. Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 27 Shammas Lane Property Address Centerville MA 02632 City/Town State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 24"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.): All in good condition Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: N/Ayears Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ® No certificate) Dimensions: 1500 gal. tank Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Stick Measurement t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 27 Shammas Lane Property Address Centerville MA 02632 City/Town State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump every 2 years with current use Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): 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.): 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): t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 27 Shammas lane Property Address Centerville MA 02632 Cityrrown State Zip Code Marcio Coelho 3/282006 Owner's Name Date of Inspection Tight or Holding Tank(cont.) N/A Dimensions: Capacity: N/A p tY gallons Design Flow: N/Agallons per day 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.): 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.): Box in fine condition Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official 'Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 27 Shammus Lane Property Address Centerville MA 02632 City/Town State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 @ 1000gal.?? ❑ leaching chambers number: N/A ❑ leaching galleries number: N/A ❑ leaching trenches number, length: N/A ❑ leaching fields number, dimensions: N/A ❑ overflow cesspool number: N/A ❑ innovative/alternative system Type/name of technology: N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Grading is good, no indications of failures of any nature t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cunt.) 27 Shammas Lane Property Address Centerville MA 02632 Cityrrown State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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 N/A Dimensions of cesspool N/A Materials of construction N/A Indication f r o groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: 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.): t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts . Title 5 Official ' Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 27 Shammas Lane Property Address Centerville MA 02632 City/Town State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection 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. tkds,� ei o 1p" / P I L\ _ 3 Y A 4 W) r B e _ '�94' CS t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official 'Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 27 Shammas Lane Property Address Centerville MA 02632 City/Town State Zip Code Marcio Coelho 3/28/2006 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: N/A Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Reviewed design plans in general area submitted to BOH ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Review of Design plan soil logs in general area t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 N Air- R5 Ole �l9 V O l J-------------------------- ` l l T>E- ' G a R' Lf I�dIG��ALq e- �G(v�q l�� A f r TOWN OF BARNSTABLE +LOCATION 627 .S�aMr,,,aS 0�4 SEWAGE# 3-7 a �11LLAGE M( Me ��( ASSESSOR'S MAP&PARCEL (/7— AP,3, INSTALLER'S NAME&PHONE NO. C. Oe 4zk 403LJ SEPTIC TANK CAPACITY 100c) 14 to V(S1 LEACHING FACILITY:(type) CJy) in(',_p 13�o ri ize) ��3 X e3z NO.OF BEDROOMS OWNER '�� PERMIT DATE: S 2.o' og COMPLIANCE DATE: S"'2�'2�cri 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) a Feet FURNISHED BY a„ W ' f Y . Al e3 37� �2 db• o 3 iy. o �•,S �S 32,E t: No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rppliratton for Bi!5poal 6p5tem Con6trUCtion Permit Application for a Permit to Construct O Repair()� Upgrade O Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. L A^A Owner's Name,Address,and Tel.No. L, QW"le� jAoti,s W +5 Assessor's Map/Parcel d- 1 ly7 ,! Installer's Name,Address,and Tel.No. CA,9,u*)o Lt, � , Designer's Name,Address and Tel.No. 0 IL Type of Building: DwellingNo.of Bedrooms Lot Size � 1.�3 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min. equi ed) 330 gpd Design flow provided �'S �'' gpd Plan Date j 1,;I"L0 o Number of sheets Revision Date Title n Size of Septic Tank 10010 C>Y3 c Type of S.A.S. ��Z� S'j61,4 •a s a. 'C-) t. t d d t f Description of Soil La 21� Cr g? 1.2, Nature of Repairs or Alterations(Answer when applicable) 95-k'"titL,s - Date last inspected: Z ®ei 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 Certificate of Compliance has been issued by this Board o ealth. Sig D' Date_ '- "j-'�C Application Approved by Date Application Disapproved py'.: C Date for the following reasons Permit No. Date Issued '. No. Fee 4L� �. THE COMMONWEALTH OF MASSACHUSETTSEntered iacomputer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Y ZIPpYfcatiou for Bioonl *pgtem Construction Permit Application for a Permit to Constructf(') Repair(A Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. a 1 S dtAMrn A$ LF,^-c Owner's Name,Address,and Tel.No. lea MAfAv s Assessor's Map/Parcel 0 4-7 l VL Installer's Name,Address,and Tel.No. l.Q pP�1rG�.t � Designer's Name,Address and Tel.No. ��Si' �, Wt yCli I 00 3or� 2(off 7-7 313 Type of Building: 1, Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( ) -Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow(min. equi ed) 3 3 gpd Design flow provided 3 gpd Plan Date 5 1,; 1"1.•0 o Number of sheets �^' Revision Date Title i_77 5�,0,.,,n.A) Size of Septic Tank 1000 q Type of S.A.S. ,.s rt Description of Soil , 44- O tall Nature of Repairs,or Alterations(Answer when applicable) 1 �, W� [� e\? i 0< Date last inspected: 'u 0 0,9 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 Certificate of g�. Compliance has been issued by this Board o ealth. i a, Sig CV l�' Date Application Approved by w i Date Application Disapproved by: Date a, for the following reasons ' s Perinit No. Date Issued - ry THE COMMONWEALTH OF MASSACHUSETTS Am�y BARNSTABLE, MASSACHUSETTS t� ��Ve)MACertificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Qkoe) Upgraded ( ) Abandoned( )by ,r, L �., at ( has been cqsctWinacqdance with the provisions of Title 5 and t e for Disposal System Construction Permit No. -1dated Installer (�( �� 'il-el 1,L Designer Fa7(/�+LGt..L 1 #bedrooms Approved design flowI gpd The issuance of this permit shale not be construed as a guarantee that the system wrr u cfion as de Date �7 �'7, �� Inspector — No. _ �".,./Y77�AV Fee ,2 THE COMMONWEALTH OF MASSACHUSETTS L�kBLIC HEALTH DIVISION — BARNSTABLE MASSACHUSETTS T15p0al *p!gtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( 0 Upgrade ( ) Abandon ( ) 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 S and the following local provisions or special conditions. Provided: Constructi must fie completed within three years of the date of thist /t Date Approved b � PP Y 7 10 .wit ► Town of Barnstable P#_ l 2,�1/ Department of Regulatory Services Public Health Division Date Y13 0 6 MAM 200 Main Street,Hyannis MA 02601 Date Scheduled Time r d AM. Fee Pd DU . Soil Suitability Assessment for Sewage in al By: �z.�f �"�r {—Q� S V� Witnessed By: A t � LOCATION& GENERAL INFORMATION Location Address 2 7 S�\AJ`A m c � Owner's Name�vA1 b2 r," (/10,s tu"S I(S Address 2.7 SLCAWt WL cam .. Map/Parcel: �f NJ\a� i t`V\VS Assessor's Ma M p O "1�_ Engineer's Name pe r M_ NEW CONSTRUCTION REPAIR Telephone# S-01—7 3-7 --4—7(. �f Land Use J'��;rA otr o�t Slopes(%) 2 Surface Stones #VIA" Distances from: Open Water Body 7 I SU ft Possible Wet Area 21_-'Oft Drinking Water Wel171 S-0 ft Drainage Way 7 SZ ft Property Line 25 k/ ft Other ft r SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ta' � Parent material(geologic) IP�Gic�t c S� Depth to Bedrock r`� (A Depth to Groundwater. Standing Water in Hole: / Weeping from Pit Face Estimated Seasonal High Groundwater f -Z d t DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: -___ in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level,. e-� A41,factor— Adj.Groundwater Level "o PERCOLATION TEST We�, Thtte.�� Observation Hole# I Time at 9" 11 I/Depth of Perc Z SY Time at 6" n Start Pre-soak Time® M Time(9"•6") End Pre-soak of O I( Jg,_ Rate MinJlnch. L 2 Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 1001 of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\,SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# l Depth from Soil Horizon Soil Texture .Soil Color Soil • . -Other Surface(in.) (USDA) (Munsell) Mottling '(Structure;Stones,Boulders. Consisterici. v1 16 y/z M ed 5ck j 2,5�' �` r � � •„ ., it DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,.Boulders. . Consistency.%. a g 8 4 U 20 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsistencX. • DEEP OBSERVATION HOLE LOG Hoe# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Flood Insurance Irate Magi Above`300 year flood boundary No— Yes Within-500'yearboundary No Yes,�.� Within 100 year flood boundary No—,< Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout.the area proposed for the soil absorption system? �eS If no what is the depth of naturally occurring pervious material? t, P - Certification I certify that on 1) ( (date)I have passed the soil evaluator examination approved by.the that the. above analysis was performed by me`consistent with Department of Environmental Protection and . the required training,expertise and experience described in 10 CMR 15.017. 1 a . Signaftue Date ✓� 1 4 Q;W-PT10PBRCFORM.DOC 05/27/2009 09:24 FAX 5084283928 CAPEWIDE 001/001 05/26/2009 13:32 50134775313 ENGINEERING WORKS PAGE 01 Town of ile Tbomu F.GeMery DimW P * Rod*Ww" Thema®McKean,DiraaW .Street,8 b,?".8 601 OliiGoo 44 hex: 5otr6304 4e::S 2L oq Skwltgc.Fer # ? 131 Ass�or's:A 1i ace1 47—!G2 -12_ -.lN, C'rus `t�� Ad a: Q.1�a� 2 it 3 Ca k*V:14 an'1!4 0 Z41 2- was issued A-PCrnatt to inSu a 27 S hak« Ln i�l;!{S b ,od on a doer .by (address) dated r l M 10 i I: 'Aw.dm-septic item new zbmm was It .y rfranvr approvedapprovedch ar s 5 to � die vl � e1lar septic 1119k, L ►,; t the aweptic ayyta reFereneed above was iasta 10' lst=W Mention of the SAS or any vftcal raiocstice at say cmppmt ��►s# r)but in amaids a with State&Local Ragi9sho s. Pin mAid l.or ; c; d"per to follow. r H OF PETER T. G McENTEE y CIVIL. .0 9 No.35109 .� �O,e• l8 T EP��►�� t Pd /ON AL ECG � OWN ) (Affix tkelper's StaM.r ) Q:}IedlN6e alDedPJK Olden Pam 3-26.04,dm TOWN OF BARNSTABLE S SEWAGE # VILLAGE ZLn . 2.�, I / C . ASSESSOR'S MAP&LOT .62 °INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /o LEACHING FACILITY: (type) + (size) G X 2 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE:7 A? Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site 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 �y a y► �G'� `' 3� �� Sa ' ., ;�� .. .. �_ C Y ASS CATT ION %l ' SEWAGE PERMIT NO. OTT J V'1 L L A G E INSTnnA LLER'S NAME ADDRESS e I U I L D E R OR OWNER ! 0 7 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7`, a?_S2 V GIX ASSESSORS NAP NO: 'ARCE! 1110, No..g �t.../_7S- w FEs....l....t67.. ...... T., THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...............To WN.............0F.......B 2NSTi�t3L� Appliration for Uhipvii al 10orks Tomitrurtinn nutit Application is hereby made for a Permit to Construct (tom or Repair ( ) an Individual Sewage Disposal System at: a- gqf,&— L,v O 5/44"719-5 L,y. /L/Arzas>a�S i`9/GLS Z6T 8 ----•-......---•-------------•--.............-----------.....----.....-------•---------..._....... ----...------•-----------------------------•-------............--------....----------.....------•- ion.Address or Lot No. G�S7Z-7z Lv�Locat 4:Z-Z-WTtrr0 I//GG� ....._...... - ----......--•----------------------•----------•------................. ..........--...................................................................................... Owner Address a ..................... n- ------------------------------------------ ..---------------------------•-----•------- _ Installer Address d Type of Building Size Lot---.-'-Z .....Sq. feet Dwelling—No. of Bedrooms...................... ........ Dwelling Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons............................ Showers — Cafeteria P4 Other fixtures .....................•-•------•• . W Design Flow........:..........s3.___.____._._.__.gallons per person per day. Total daily :low____._..._____3..........................gallons. WSeptic Tank—Liquid"capacity_A!"..gallons Length__B�` Width._'4.2._...... Diameter---------------- Depth......G'�.... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------/-------- Diameter....... ®........ Depth below inlet......G........... Total leaching area....ZG7....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---- f-! �__. ' ' �u ................. Dated:....`g 1,98J Y-------------------. Test Pit No. 1._L_.z.._..minutes per inch Depth of Test Pit......! ---•- Depth to ground water_-___".............. (i, Test Pit No. 2.... .Z...-minutes per inch Depth of Test Pit.....:� ..... Depth to ground water...... ............... a' •-•••-•••--•......--•--•-•••-••---•-•••••••••-•••••••--•-----•---••••.............. ...B�"�IZA✓�z x84'1- i4.0-" Co/�-ij.sN.------'S.�a.-----�-� '-/�/.2--------- .........................................:............................... U W x ----------------------------------------------------------------------------- ---•-•--•••-••••-••---•••••••••-•-----------------•---•••---•-••••••••••--------•••-•••--•-•••••--••-••••••...._......... 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.i "UE, ;of the State Sanitary Code— The undersigned further agrees not to place the system in operation til a Cer " &ofpli, nce has been issued by the bo rd of health. Signed........... .......................... }"�. ------ Application APPr Y••-•••.............• , ...„ Date ..3.1-s .......................... f,/ tJ Application Disapproved for the following reasons--------------------------------------------------------------•--•--------------------------•••-••-•---.....----- ...........-••••••-----•-•-••••-•---••••-•....--•--•••••••--••-•-••••--••------•••-----••------•...........•-•--••-----...••-•••--•----•••-•••-•-•••....................................•............... Date Perm�No � ......1.7,_� ----------------------- Issued....----.:. ...U.Z�............ Date ` ¢7 /d Z f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , ppliratilan for Disposal Works Tumtrnrtiun 11amit Application is hereby made for a Permit to Construct (., ) or Repair ( ) an Individual Sewage Disposal System at: L,,� '/ q�1 ��7s LAJ. �7/�-i srnr�s /�'/LGS �s7 8 ................. -•--...---------..............---•--...-•--------•-....---...•-•---------•-------••••-•-•••....... Location-Address or Lot No. Z1-s77-7Z Ir//I'Z>E LnLV/GGE------ Owner Address a ----•••••••-•••......�--4...._0• ------------------------------------;..... ......-------•------------•........._... Installer Address _ Type of Building Size Lot__.5 Z..! _'_.._._Sq. feet Dwelling—No. of Bedrooms................•. ............_..........Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other fixtures .--"-"-""---•---------------•--•-••-•-• - W Design Flow..................:•�.'........___...•........gallons per person per day. Total daily flow__...........33�''........._.........__gallons. 1x Septic Tank—Liquid capacitylpbq_.gallons Length._e.�G....... Width.4.....`.. Diameter________________ Depth_-5 &''./.._. W Disposal Trench—NTo. .................... Wid1th.................... Total Length.................... Total leaching area____-_-.______..._.-sq. ft. x Seepage Pit No---------1--------- Diameter....... �?......... Depth below in. Total leaching area_..z�7.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ Percolation Test Results Performed by... ................................................`r ..................... Dated:------- ----- ---- ------------ aTest Pit No. LA__Z'._____minutesperinch Depth of Test Pit----- ..... Depth to ground water_.___"'................ Test Pit No. 2._L_7-_"-"_minutes per inch Depth of Test Pit----- _..... Depth to ground water........................ p� .........................•------•-••.-•---•...----- ..............-----••--•--......__.......-•---•........................................................ p ...... '_ Description of Soil..._..... "- -.--Vov2l,,1-r,•_..�....� '.Via.-�"----" 4-----8+ /Z!.....C......"-""""-"""---"""-----"""--• x e4"- '144 Cam.�-iz3�` 'Y'4'vv V aw—blE_G... ............... V •••---------------••-••....-. W ---------------- -----------------------------------•-•-•--•--------------••••••••-••••••-••••-•...._.................----------•----••••--•-•••---••-•••-••--••-•............_........_......_.....•--- UNature of Repairs or Alterations--Answer when applicable................................................................................................ ..•--------------------•--••---------......_--------.....--------•••--••-•----•••-••........•-•••...--••--................------••--•-••....._..----------------- -----------------•-----•--------- Agreement: . The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of T?T1-7 5 of the State Sanitary Code— The undersigned 'further agrees not to place the system in operation ntil a Cer ' ate of pliance has.been i uWbtboard of health. Signed.---- d L- � ..__.. Date Application APpro y------------------------- .. ......... ._5_. .7_.. Date Application Disapproved for the following reasons:"-"-"-"-"""...................""--------""-""-"-"--"---"---.......--------------"---------............••-•-..... ..............................................._......................................................................................................................................................... Date Permit No...... ----------------------- Issued-......... ----------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............T v tr+//1..........OF.......... .RKn �'��'G G-� . . .............................. Cfuntif irab of Tomplianrr THIS IS TO CERTIFY, Thy th Indio ual Sewage Disposal System constructed (✓'S or Repaired ( ) �v // Installer. J t Tj,( has been installed in accordance with the provisions of Ti i TIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. -•--••---------------------- Inspector..... .... —7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r Ir//✓.........OF...........6/9-4AI.SrA/ Ge ..... FEE.....Z. ......... Permission is hereby granted............ "-----------------"---•--------•------------------".-"-"".-.-----------.-.---•--•---••---- to Construct (t/) or Repair ( ) an Individual Sewage Disposal System at No.............4 t.-..._�---- ►..--...�'ak ,,......_._..... . Street +� as shown on the application for Disposal Works Construction Permit No....V, `.J."l._.7__ Dated.......... ..-- �r—� "------------- -� ••- - ....................... Board 6f'health DATE----------��'�" --- ------------ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS A, 'r J/7'�L-� /rL�tT✓ SN2T ! o� Z ~SM&GTS LOCATION 4609�W-M&.4 Cti�r�;l �! , SCALE . ":. ?.�. . . . DATE ?: PLAN REFERENCE , ,8, ^!G LeT!y.q ,51-bW.V 5AI 4; 4-A/ 3B97.3. . . . . . . . . r h � gwxv. Too oF' LoT 7 ( euposd� ' �� LoT&ll 7�sT N U i A o EDW., L tll C n Ar � I _ 4, 2- o� 'L SN CZT's 48,o 0 TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS o, • .11 0 4"CAST IRON 1 MAX. • � 12"MAX. OR SCHEDULE 40 4"SCHEDULE 40 PVC.(ONLY) P.V.C. PIPE PIPE - MIN. LEACH ° PITCH I/4"PER.FT PITCH 1/4"PER.FT PIT o PRECAST D' INVERT Jj.".' LEACHING ° EL. SEPTIC INVERT INVERT p . �`: PIT ORSEPTIC TANK EL ,�� DIST.INVERT EL.I-V4. ' ; >= EQUIV.EL..4 -C8 . .. GAL. INVERT BOX `t Ua o °.INVERT ww o 3/4��T0I1EL 4Z;8aWASHED o w STONE t DIA.:!�d PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE SOIL LOG WITNESSED BY : DATE TIME. BOARD OF HEALTH TEST HOLE I TEST HOLE 2 G-�1.�sj7z/� �' .L%GG�� ENGINEER ELEV. . 4 8v . . . ELEV. .�5, 24! Im77)7;7- WooDLogv� lwooD 4o/47 S4-5., 24•• Sc,a,so,�. DESIGN DATA Ez. 4?,8o Ez. 43,so .3 NUMBER OF BEDROOMS C,p�y� G2AVG-Z TOTAL ESTIMATED FLOW . . 3�f? . . . GALLONS/DAY Ott ,emu BOTTOM LEACHING AREA 78 So. . . SO.FT. /PITIC,P D. E2.37.8 SIDE LEACHING AREA . . ./ �•S�? . . SQ.FT./ PIT/C./? D. CogYzse GARBAGE DISPOSAL .�o'`�� • • • •(50 /o AREA INCREASE) $ TOTAL LEACHING AREA . .ZG7�.aa . SQ.FT 6iZs►vc� GizAvErL /¢¢" �z, 3z.Bo i4st" d?,33.So PERCOLATION RATE LL a`S � .�/+/J. MIN/INCH LEACHING AREA PER PERCOLATION RATE . d.. SQ.FT./.r,P,A -WATER ENCOUNTERED NUMBER OF LEACHING PITS eT dNoT�/ APPROVED . . . . . . . . . . . BOARD OF HEALTH •of-c?D!�!� DATE . . . . . . . . . . AGENT OR INSPECTOR •O IS N,' N ' Lo o 7 8 v 'Rs f L� t �� N s o �;tiELLEY f No. 2�100 /Ile6 �+3 PETITIONER atiAL LE ; i� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION a Map:_47_ Lot: Par:_162_ TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE MEIVE® PART A CERTIFICATION Property Address: 27 Shammas Lane JUN U 4 2002 Marston Mills Owner's Name:Tim&Brook Fays TOWN OF BARNSTABLE Owner's Address: salve HEALTH DEPT. Date of Inspection: 5/21/02 Name of Inspector: Dion C.Dugan Company Name:_ 1543 Main St. Mailing Address: Brewster,MA 02631 Telephone Number:_508-896-9390 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: _5/21/02_ 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: *Recommend: Maintenance pumping 3 5 yrs. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 27 Shammas Lane Marstons Mills Owner's Name:Tim&Brook Fays Date of Inspection:5/21/02 Inspection Summary: Check ARCM or E/ALWAYS complete all of Section D A. System Passes: _X_ 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: N/A 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: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:27 Shammas Lane Marstons Mills Owner's Name:Tim&Brook Fays Date of Inspection: 5/21/02 C. Further Evaluation is Required by the Board of Health: NIA Conditions exist which require further evaluation by the Board of Health in order to determine if the system Ts 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 27 Sham as Lane Marstons Mills Owner's Name: Tim&Brook Fays Date of Inspection: 5/21/02 D. System Failure Criteria applicable to all systems: You must indicate`ryes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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.] _NO (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 Systems:N/A 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 _N/A_ the system is within 400 feet of a surface drinking water supply _N/A_ the system is within 200 feet of a tributary to a surface drinking water supply _N/A_ 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 27 Shammas Lane Marstons Mills Owner's Name: Tim&Brook Fays Date of Inspection: 5/21/02 Check if the following have been done.You must indicate`des'or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _X Were any of the system components pumped out in the previous two weeks? X — Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? _X _ 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? X _ 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. X_ _ 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 i i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 27 Shammas Lane Marstons Mills Owner's Name:Tim&Brook Fays Date of Inspection: 5/21/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3 Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_330_ Number of current residents:_4 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)): 2000: 000, 2001: ,000 Sump pump(yes or no):_no Last date of occupancy:_OCCUPIED COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A 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:_pumped June 2001(owner) 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 X_Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy NO 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: _Installed 7/27/87 B.O.H.Records Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 Shammas Lane Marstons Mills Owner's Name:Tim&Brook Fays Date of Inspection: 5/21/02 BUILDING SEWER(locate on site plan) Depth below grade:_21 _ Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_12"_ Material of construction:_X_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 Gallon Sludge depth:_<1" Distance from top of sludge to bottom of outlet tee or baffle: 30"_ Scum thickness:_<I" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:_by tape and rod Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): pumping not needed at this time.Tank and tees in good condition; no sign of leakage *Recommend:Maintenance pumping every 3—5 yrs. GREASE TRAP:_N/A 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 bale: 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.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 Shammas Lane Marston Mills Owner's Name:Tim&Brook Fays Date of Inspection: 5/21/02 TIGHT or HOLDING TANK:_N/A (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:_YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box is level with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A (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.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:27 Shammas Lane Marstons Mills Owner's Name:Tim&Brook Fays Date of Inspection: 5/21/02 SOIL ABSORPTION SYSTEM(SAS):—YES—(locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: one 6'x 6'leach pit with 2'of stone— leaching 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.): leach pit found with 42"of liquid in it,no signs of failure CESSPOOLS: N/A (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 pondmg,condition of vegetation,etc.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY:—N/A(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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:27 Shammas Lane Marstons Mills Owner's Name:Tim&Brook Fays Date of Inspection:5/21/02 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. 14aoO '�7 A l fi ,b 32, _ b 4to �� FE - �1 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 27 Shammas Lane Marston Mills Owner's Name:Tim&Brook Fays Date of Inspection: 5/21/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 281_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) X Accessed USGS database-explain: You must describe how you established the high ground water elevation: by USGS atlas HA—692 �i r' TROY WILLIAMS SEPTIC INSPECTIONS C IONS Certified by MA Department of Environmental Protection ) 760-1819 40 Old Bass River Road �p N�� 2 co South Dennis,MA 02660V O. k17 /�O;L cofnmmeam, of Massactxu ExeCU" Offlce of Envkmrentd Affairs Department of o . . �o P� Environmental Protection %Wam F.Wald OoNmor David twhs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART A CERTIFICATION Property Address: a 7 S a "^°` 6 �tar 5 +�+� *Address of Owner. Date of Inspection: 1.1 Aa o /q r / Of different) L°v� f{�` 14 Name of Inspector: �ljo yy W;I I. Company Name,Address fnd Telephone Number: 5e-<- c, boat. 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 inspection..The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date:, � The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: _LI/ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components reed to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If'rot determined',explain why rot) The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 4/15/9S) t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 02 7 cSh •,,c. � s Owner: M: C- Date of Inspection: ,/ /2ti/9r BI SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY.AND THE ENVIRONMENT: The system has a septic tank ano soli adsorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303, The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a S�� S Owner: A,I G 4 G 1 Date of Inspection: �/ lao /4 S DI SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day'flow. Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR S.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ` Property Address: 7 .S K% w,u S Owner: Date of Inspection: Check'if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with WA. , The facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. ✓AII system components, excluding the Soil Absorption System, have been located on the site. L/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or a proximated by non-intrusive methods. The facility ownp• (and occupants, if different from owner were provided with information on the proper maintenance p ) p p pe to ce of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: a Owner. ro Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:,22 b gallons Number of bedrooms: oZ Number of current residents: Garbage grinder(yes or no):,A16 Laundry connected to system (yes or no):65 Seasonal use (yes or no): No Water meter readings, if available:_ 2'y = Sd oc, 0 4 4 /. 4_ foe D oo ate. Last date of occupancy:Qc-��o. COMMERCIAUINDUSTRIAL: 1W14 Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)/_/o If yes, volume pumped. gallons Reason for pumping: TYPE O� 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)L✓0 (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: � G Date of Inspection: 11/.2o SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: ✓oncrete _metal _FRP—other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: a Scum thickness: Sly Distance from top of scum to top of outlet tee or baffle: ra Distance from bottom of scum to bottom of outlet tee or baffle: /G Comments: (recommendation"for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) _PUG �, h✓c co •, «t 4 .�. �� v 4— .e.4- A J A r,,; •� 1�c , �, c o v d sr. /KO s J / s—c -<- r� o+., P" e h J -v 6 t so✓r.,.ono( -f'a �. S y ✓,e 0 rD d o✓ Gel O r A,I rg>l�O� 6✓ J GREASE TRAP:/V�r, (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —Other(explain) Dimensions: scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom ni coo- r- honor- or ou?tet tee or bame Comments: ,recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ;revised 8/1S/9S) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C , CC / SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP other(explain) Dimensions: Capacity:_ gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: !/ (locate on site plan) Depth of liquid level above outlet invert: e') Comments: mote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) �— ✓�a � �./� U ✓�cy PUMP CHAMBER:L1491 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :n PART C SYSTEM INFORMATION (continued) Property Address: Q L 6^-4. w.a S Owner: Date of Inspection: I/ /a O / r SOIL ABSORPTION SYSTEM (SAS):_Z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) if not determined to be present, explain: Type. leaching pits, number: O h c X 6 c.o c leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc. CESSPOOLS: N/�9 (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 (cesspool must be pumped as part of inspection) 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION (aontlnuecl) ' Property Address: �2 a rti�K f Owner. Date of In spection:wn: I SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' dye o)616 4 3° . 3a' yd` Sa � w o? 'S A) C DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater level method of determination or approximation: 4; /r u v at A! -Cjo!'1- c cr c, r 4V LU 740 c. f3 . .S- . 1 (revised 8/15/95) 9 PROJECT 'TIT.LE .r �• t; i 1 \ r i yG.r -- •f�,�� N_ _ (J C� y \1\ P ft ARED FOR i 9 � fin` Construction Company, lin preStde�zt o rstons Mills,MA 02648.508-420-1340 i•' 1 x w y ` r e _ l _ �- ! - — - - DWG NO. AWN 16gz yin SHEET 'OF F'MVJf—I., I �—� j . 00 ' 2 1i� w, w�'rs �,� z1 00 p R a j T clPREPARED FOR 77 J. I. Central Construction Company, Ins Steve Devlin •President j 261 8lackthom Drive•Manton MR11s,MA 02648.508420-1340 SCALE ' �.._._..__.w�l`;;�t 2.i•� �-f-a DATE DWG NO. DESIGN 1 CHECK DRAWN JOB NO. ISHEET OF �I/ T 7 . PROJECT. TITLE - _ b 'TZIhJs. -- FM r• S� /X xu -4 . i 1 7. ocri PREPARED ' FOR '= :•��b *� SL i S La�tt..u�c f"' 41 (il U_r , ;I Cent®I Construction 'Company, I ::--- V E �S2 �-— - nT c :.._'------ --- Steve Devlin •Pruidenr -- -- 261 Blackthorn Drive•Marston ills,MA d2648.508-420-131 4 SCALE 4 �A DATE / Z Q DWG. . NO..' DE SfGN CHECK DRAWN . ,JnH NO SHEET.' Of PROJECT TITLE Nam•, A;' �, I ��I�VYI..�..-. �.��{ ~-."�-� '7`yjJLS •.: ro I 1 i j a S t '—' -• \\ _ i'_ `� ICI • m iF ma 1 PREPARED FOR i s` t. zk�ra Z �<< '► 2.4 3 t o Central Construction Company, h ---- i 261 8taddhorn Drive•Marston Milk,MA 02648•SOS 420-1340 SCALE 4 = t r 0 1 DATE / Z (03 DWG NO, DESfGN �nOv .jL CHECK DRAWN r_ I . C)R Nn ISHEET OF. _ - PROJECT, TITLE . Cl 10 v. O /V f i f ` PREPARED FOR 2�1..6 =a Central Construction Company, Inc. Steve Devlin •President m 261 Blackthorn Drive•Marston Mills,MA 02648.508420-1340 _ - SCALE g = 0 DATE DWG NO. DESIGN SV106VLh• CHECK DRAWN JOB NO SHEET OF PROJECT TITLE ~ It a IT y i ! rli C" S + F I /_ i ✓ iC �. PR PARED FOR �} V�->. • Construction.Company, In — t lin •President actor 3rstons Mills,MA 02648.508420-1340 f(Sca r i r i S i I y .fi ' ` 1 ! I �1I '_, i —f i i if Io 1F11 ( _ a t - -------- - Dif DWG NO. t _ 1 i f-(�(� �Lzif�i�•`3L '-�- �i I I rYti �._,�' r � et i ti\ I 1 DRAWN rat=FT r. OF t I . . ,. PROJECT TITLE on .12 To 2 20 �t G ZL(.If T. fz : (f , M g �. r .t / i X. e,. j 9�D D6 yy99 ' i ;_ ,� ?.r PREPARED FOR 21. o FA c; —Zak.= _. : 2�Z �o Central Construction Company. -` - f�I Steve Devlin -I'rerident j� do orn Drive•Mar b48.5t}8 Mills,MA -4 D-1 261 Bla th stags 02 . 2 � SCALE S N ! r ;, F. O ' r � DATE / Z . 4 DWG NO,' I. DES(GN IVJ�s✓i ,; -CHECK DRAWN cr r�FT Of 1 , , ( f�- PROJECT TITLE ' I fL I�J �- % � a IfV 10 AZ NEW SMOKE-DETECTOR RE ARE NOW LAW. EVEN THE ADDITION OF A, SMOKE DETECTO S O.K. '<, ��`, ~N - "l �wr NEW BEDROOM WILL TRIGGER AN . :'� e l UPGRADE OF THE SMOKE DETECTORS FOR THE WHOLE HOUSE. YOU MUST RNSTABLE DING DEPT. PLAN ACCORDINGLY AND HAVE YOUR PR PARED FOR ELECTRICIAN TAKE OUT THE APPROPRIATE PERMIT AT THE FIRE DEPARTMENT. 04 "rV- /LCv r4. A'11 o Construction Company, 1 d . r� Z n President � na o irstons Mills,MA 02648.508420 1340 1. s4tfl " — A f 1 11 I 1 11 r DWG Ni. or •i I __ DRAWN r ; �r 7� PROJECT TITLE -- --- CC PARED FOR 3 PRE - . A c-r e ( I I - Central Construction`Company, i Steve Devlin •President 261 Blackthorn Drive•Marsions Mills,MA 02648.508A20-134 l � SCALE ( - a ' r 'ILI DATE / Z b DWG NO DES[GN rs�1}r;Vl sL i CHECK ------------ s DRAWN 1OF3 NO SHEET OF k 0-0 Z� s I I <- s r i { PREPARED FOR . r _ _. ._.t. i 77 Centr®I Construction C ompany, In( Fj I Steve Devlin •President I , k , J} I 261 Blackthorn Drive•Marstons Mills,MA 02648.508420-1340 1 SCALE f 0 DATE DWG NO. DESIGN S �J GVLi� CHECK DRAWN JOB NO. SHEET OF 4 1 4 jzO IN f ^PV Pop. t A Y ±/ N ROpa C S 89.13'55" W _/ Cb =1 ®� � Cb 0 361.93 __ 99.221; E vo i /� /S?� Cb x 99.57 _�0 �. v /x 94.30 i / �-� I �p E Y x/97.96 ,/ 1 �.: ' .. f .4 99.21� N o " 1007 ::PAVED : "DRIVEWAY �, o'',ojr:', i. o a Roce Lon ' i�'Q� 1j// , x 99.33 LOCUS o 187.56 , v, o x 98,66� Oj �,�39' i fT1 `u o 4 OK /- S ,` p S 89.13 55 W Co'0.50 �e/ Oj x 97s8�, % 00,7s ; bOCk /� a a �, � � . •,�.:.. . 1,o ,6 LOCUS MAP 1 39 > .w NOT TO SCALE 10 is o GENERAL NOTES: , ,' ,� ' `'. �•:�•., . .•�::• :. a.8 .:;,.•• :., r....• . ..: ;�,i: r•,,� , 1ovo1 / � : ; . ' 8 ,:.. -3 . ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. co FA V�D9,92 _ 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS %:.. DRIVEWAY �• OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 0.32- 0.33 ` i EXISTING LEACH PIT V LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: / i• TO BE PUMPED, FILLED WITH / r 9e.7a:.. .:, J 310 CMR 15.405(1)(b): I > `.•' .,: p, I " 100,33 / SAND AND ABANDONED 9 . 8i;•,.. 100, 2 / 1) A 2' variance to the 3' maximum cover requirement, for no greater t•';;-.=: ()G 17 / than 5' of cover. S.A.S. shall be vented and H-20 Rated. 8 �o s 10' 1 �J TP-1 ' i 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR ✓R/t �I�l'9 i, / TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE / t/ GARAGE 2v`1oosLEEVE WER I I \jr / _2 3� EXISTING SEPTIC TANK DESIGN ENGINEER. TOP OF TANK, EL.=99.14 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING w I WALK IN (OUT), EL.=97.80f WALK 1.o FROM THOSE SHOWN HEREON SHALL BE REPORTED,,-TO THE DESIGN in i -o x 100 1 '100.9 1 �1 ENGINEER BEFORE CONSTRUCTION CONTINUES. � P to 00 i o��y x l0y',86 INSP POR S Benchmark Set 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. I � i DEC I 27,. NT OUTSIDE COR. BOTT. STEP 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF O cV O i .EXISTING i EL.=101.26 (Assumed THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OFF S to HOUSE (#27) i is HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. (+ i 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. }w_ 8. THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PROPOSED S.A.S. PORCH t--12i Z 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS �s ALK \\ DECK 2 83r ' 5.7' N O 1 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE x loosa O 1 DIRECTED BY THE APPROVING AUTHORITIES. �\ WALK �\rn i 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE t.� r THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING `/02 CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS \� LOT 8 IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 52,143f S.F. REPLACE WITH CLEAN SAND AS. SPECIFIED IN 310 CMR 255(3). � • . OF 12. ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC SYSTEM Map 47 ` Q�� MgsS9c COMPONENTS NOT SHOWN ON THE PLAN. �v Parcel 162 �� PETER T tiG 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND McENTE E � o . J' IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. -' CIVIL ' No. 35109 c/sz��° �� PROPOSED SEPTIC SYSTEM UPGRADE PLAN 27 SHAMMAS LANE, MARSTONS MILLS, MA '5 `� Prepared for: Capewide Enterprises,� P.O. Box 763, Centerville, MA 02632 1 `� `� C Engineering by: SCALE DRAWN JOB. NO. 89.43 � OWNER OF RECORD 1"=30' P.T.M. 139-09 s 85.22'S5" L=85.57' PAULo GUALBERTo Engineering Works, Inc. E p �� - 27 SHAMMAS LANE 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. R=2084.32' - MARSTENS MILLS, MA 02648 (508) 477-5313 5/19/09 P.T.M. 1 Of 2 r' NOTE: TO PREVENT BREAKOUT, THE PROPOSED • FINISH GRADE SHALL NOT BE < EL:97.13 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. (3) 5" DIA.OUTLETS INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT INSTALL INSPECTION PORT OVER END UNIT 15 5" 16" 2" OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE T.O.F. F.G. EL: 102.13(MAX.) CHARCOAL EXISTING F.G. EL.=100.4f F.G. EL: 101.5f MAINTAIN 2% GRADE (MIN.) OVER S.A.S. J- 12„ 4 15.5" , CONNECT INSPECTION 6" L = 83' L = 6'(MAX) PORTS AND VENT TO ® S=1% (MIN.) ® S=1% (MIN.) MANIFOLD p 4"SCH40 PVC 4"SCH40 PVC 2" 10"1 6 11.3" TO H-10 LOADING 14" INVERT EXISTING 48" LIQUID Q �(LEVELGASADDD INV.=96.97 PROPOSED INV.=96.80 2 TRENCHES W/5 UNITS AT 6.25'/UNIT = 31.3' D-BOX INV.=97.80t D-BO INV.=96.74 SOIL ABSORPTION SYSTEM (PROFILE) EXISTING 2 OUTLETS (MIN.) EXISTING 1000 GALLON SEPTIC TANK ESTABLISH VEGETATIVE COVER BACKFILL WITH CLEAN SAND (NATIVE OR PERC SAND) UNDISTURBED -75 GROUND NOTES: `:'' 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP EL=BREAKOUT EL.=97.13 INVERTS, PRIOR TO INSTALLATION. INV.EL.=96.74 2) D-BOX SHALL BE SET LEVEL AND TRUE TO I.. 76" -I nMMiiFW GRADE ON A MECHANICALLY COMPACTED SIX BOTTOM EL.=95.80IIIII II 4IIIII II INCH CRUSHED STONE BASE, AS SPECIFIED IN 5.7' PROFILE 7 2.NC TWICE THE EFFECTIVE WIDTH) 2 8 310 CMR 15.221(2). 5' MIN. ABOVE GROUNDWATER TRENCH ( TRENCH 3) INSTALL INLET & OUTLET TEES AS REQUIRED. EXISTING 4) GAS BAFFLE TO BE. INSTALLED ON OUTLET TEE NO G.W., EL.=90.2 - MATERIAL SUITABLE AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. - �- 16" 2 TRENCHES WITH 5-16" (H-20) ADS BIODIFFUSER UNITS 11.2" SEPTIC SYSTEM PROFILE MIN. REQUIRED SEPARATION = 2 x EFFECTIVE WIDTH (5.7') TYPICAL SECTION N.T.S. M.T.a f 34" -I SOIL LOG SECTION END CAP DESIGN CRITERIA DATE: MAY 19, 2009 (REF# P-12561) 16"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT SOIL EVALUATOR: PETER McENTEE SE#1542 NUMBER OF BEDROOMS: 3 BEDROOMS WITNESS: DSVID STANTON r HEALTH AGENT MODEL 16" HICAP SOIL TEXTURAL CLASS: CLASS I ELEV. TP- 1 DEPTH ELEy. TP-2 DEPTH LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT DESIGN PERCOLATION RATE: <2 MIN/IN EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY DAILY FLOW: 330 G.P.D. lffzme DEC 26.5' 100.2 A 0 100.2 A 0 SIDE WALL HEIGHT 11.2" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. DESIGN FLOW: 330 G.P.D. SANDY LOAM SANDY LOAM 10YR 4/2• 10YR 4/2 OVERALL HEIGHT 16" GARBAGE GRINDER: NO 99.5 8" 99•5 8" OVERALL WIDTH 34" 4640 TRUEMAN BLVD LEACHING AREA REQUIRED: (330) = 445.9 S.F. � �? B B HILLIARD, OHIO 43026 0' SANDY LOAM SANDY LOAM 13.6 CF 74 10YR 5/4 10YR 5/4 CAPACITY (101.7 GAL) ADVANCED DRAINAGE SYSTEMS. INC. EXISTING SEPTIC TANK: 1000 GALLON CAPACITY I- 26 8. 96.7 42" 96.7 42" PROPOSED D-BOX:: 1 INLET, 2 OUTLET (MINIMUM), H-10 RATED C1 PERC C1 PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 2 TRENCHES WITH 5-16" (H-20) ADS BIODIFFUSER PORCH 283,-/ C57, MED. SAND 66 MED. SAND 27 SHAMMAS LANE, MARSTONS MILLS, MA UNITS IN EACH TRENCH FOR A TRENCH LENGTH OF 31.3' T 2.5Y 6/4 2.5Y 6/4 10% GRAVEL, 10% GRAVEL Prepared for: Capewide Enterprises, P.O. Box 763, Centerville, MA 02632 BOTTOM AND SIDEWALL AREA: Engineering by: SCALE DRAWN JOB. NO. (GENERAL USE APPROVAL FOR 7.9 SF/LF OF BIODIFFUSER) 90.2 120" 90.2 120" Engineering Works, Inc. N.T.S. P.T.M. 139-09 10 UNITS x 6.25 LF x 7.9 SF/LF = 493.75 SF PERC RATE 1<2 MIN/IN. ("C" HORIZON) 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 x 493.75 = 365.4 GPD S•A•S• LAYOUT NO GROUNDWATER ENCOUNTERED (508) 477-5313 5/19/09 P.T.M. 2 Of 2