HomeMy WebLinkAbout0141 SPUR LANE - Health '741 Spur Lane
Marstons Mills
A = 027 - 112
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M. Commonwealth of Massachusetts ..
Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
141 Spur Lane
Property Address:.
..
Schneider Family Trust
Owner
Owner's Name
information is Marstons Mills MA 02648 5/1.3/13
required for every
page: City/Town - . 'State Zip Code Date oflnspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness.checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer;
use only the tab -
1. Inspector:
Key to move your
cursor-do not... Matthew Gilfoy - - -
use the return:
key. Name of Inspector
- B & B Excavation;Inc. - - -
�. Company Name
14 Teaberry Lane
Company Address
Good Forestdale MA::.' 02644 _.
City/Town State Zip Code
508-477-0653 S 113640
Telephone Number License Number =
B. Certification
certify that I have personally inspected the sewage disposal system at this address andthat the
information reported below is true, accurate and complete as of the time of the:inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
Passes. ❑ Conditionally Passes ® Fails
Needs Further Evaluation by the Local Approving Authority
5/13/13
Inspector's ignature 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
thesame or different:conditions:of use.
't5ins•11/10 Title 5 Official Inspe on rm:Subsurface Sewage.Disposal System:-.Page 1 of 17
I
Commonwealth of Massachusetts
ti. W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t
y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
a C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is Marstons Mills MA 02648 5/13/13
required for every ,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
t5ins•11/10 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
^M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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
❑ El 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.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 141 Spur Lane
Property Address:. ...
Schneider Family Trust
-Owner Owner's Name
information is Marstons Mills MA 02648 5/1.3/13
required for every
page:" - City/Towni State Zip Code Date oflnspection
C. Checklist ..
Check if the following have been done..You must indicate"yes" or"no as to each:of the following:
Yes: No
El ® Pumping Information was provided by the owner, occupant, or Board of Health
❑ 0 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
_..
E ® this inspection?
Wemas 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?
1Z El 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
❑ ® aPP roximation of distance is:unacce table)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
3. 3
Number of bedrooms (design): Number:of bedrooms(actual.);
p ,DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): ..
330
t5ins.-11/10 Title 5 Official Inspection Form:Subsurface Sewage_Disposal System:-:Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [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 d n/a
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: April 2013
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
L
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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
t ❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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:
1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
grade:
Depth below
22"
p g feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >100 from well
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
Depth below grade: 16"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:
5"
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) r
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
33"
° Y
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 16"
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 appears to be structurally sound. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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.):
r
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•1 1/1 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
r
Commonwealth of Massachusetts
title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box needs to be replaced. Also, shows signs of hydraulic failure
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.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 .5/13/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 2 flow diffusers
❑ 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 is in hydraulic failure and must be replaced
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
X
In of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
41,
t5ins•11/10 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
y< 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
.
page. Cityrrown 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:
0. hand-sketch.in the area below
0 drawing attached separately
L
A1 = 23'G "
A2 = 28'
b 1.C? 1
t5ins•11/10 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
- W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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: >20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
gw 26' below grade
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 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
2 2
Commonwealth of Massachusetts w/�
`M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Spur Lane ;
Property Address
Autumn Devito "'
;.R
Owner Owner's Name
information is '
required for every Marstons Mills MA 02648 6-21-17 Cq
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
auwn�npni��
on the computer, �������\ZN OF Mq
use only the tab 1. Inspector: ��y�k?;.• ••.ssy'%,�
key to move your ��
cursor-do not JAMES N
use the return James D.Sears
ke Name of Inspector 5
y�
ewide Enterprises
Com %* ' • *�
Ca �,•.,�,� p
ICI Company Name zF �1�GAO;
153 Commercial Street 4q,���,sI�?tE 'X\8o
Company Address
» Mashpee MA 02649
Citylrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below.is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-21-17
pector'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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer„if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank D Box and two pipe field.
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.doc•rev.6116 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
141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if ry
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):
y ❑ 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:E4aluation 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:
El Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 ,Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in MEN=is less than 6" below invert or available volume is less
than '/2 day flow L£ACH!/dG
t5ins.doc-rev.6/16 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
141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown 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:
❑ Z a 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 largesystems, 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.doc•rev.6116 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
M 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 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
°�� ,•'•y 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and two pipe field.
Number of current residents:
4 I
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
Seasonaluse? ❑ Yes ®. No
Water meter readings, if available (last 2 years usage (gpd)): 2015-66,000Gals
2016-50,000GaI s
Detail:
Note : Well water for irrigation only.
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
a W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
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: NA
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, distrib
ution 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection "Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
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:
Tank NA / Box and leaching 2013 permit#2013 -247
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 28"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 16"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast H-10
2
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 117
Commonwealth of Massachusetts
a W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. City(rown 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 NA
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? Asbuilt- Plan -Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 16" below grade w/inlet cover at 8". Note: Outlet cover under
chicken pen. In and outlet Tee's. No sign of leakage or over loading.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day .
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm-in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 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
141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is Marstons Mills MA 02648 6-21-17
required for every
page. Cityfrown. 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.):
D Box is 16"x16"-43" below grade w/cover at 1'. Box is clean and solid w/two line's out. No sign of
over loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number.
❑ leaching galleries number:
® leaching trenches number, length: (2) 3.2
❑ 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.):
Leaching is two trenches (32'x3'x2'). Leaching at around 5' below grade. Ck D Box and camera
out. Prob above and beside. No side of over loading. Pipeing and hole's clean.
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Spur Lane
Property Address e
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 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
,M 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown 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
�B
�g�lc
o _
e _
a
3
/4_a
t5ins.doc•rev.6/16 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
,M 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-21-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
�p
Estimated depth to high ground water: 1 +
• feett
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: 6-19-2013
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:
T.H. on Design plan 10'+ No G.W.. Bottom of Leaching stone 5' below grade. Bottom of Leaching
stone 5' above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 141 Spur Lane
Property Address
Autumn Devito
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 6-21-17
page. 67ty-rrown State Zip Code
Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17„
TOWN OF BARNSTABLE
LOCATION /L/i Spur LiJ SEWAGE# Z O 13 - 2 y 7
VILLAGE fy). Mi I Is ASSESSOR'S MAP&PARCEL 2 z7 - /J Z
INSTALLER'S NAME&PHONE NO. ,(-3�►.i3 EXcaUCL-A 10 0
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY:(type) T�cn c h c S (size) Z x 3 x 33
NO.OF BEDROOMS 3
OWNER Lr.,n r S
PERMIT DATE: ']-Z - 13 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching•Facility(If any wells exist or<"
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
A� -
Az- a1'G " '
gz .
A3: 3y" r.
k
B3- a9'
A4" 31# 9 " RcAR
By -So ' C3
:mq .
OD. .
No. O�
Fee (
/�'
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Applitation for !Bisposai 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,j and Tel.No.
Assessor's Map/Parce . d �14(S Al I J(hne(UCit
In aller's Name,Address,and el.No' Vf5esigner's Name,Address,and Tel.No.
'Inq
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 1 Io gpd Design flow provided S L4 01 gpd
Plan Date 7 I I I I Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Bo o Health.
Si ned Date
Application Approved by Date Z0r3
Application Disapproved by Date
for the following reasons
Permit No.��1 ZN Date Issued 77 17,/ZO 13
Fee
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF,BARNSTABLE, MASSACHUSETTS
0[ppiication for �Disposai M pstem Construction permit
Application ffor a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. +� Owner's Name,Address,and Tel.No.
Assessor's Map/Parce - A / A 15chne(c(e r'
ti Installer's Name,Address,and el.No. 51esigner's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
,�.. Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures q
Design Flow(min.required) _ gpd Design flow provided 3 ` "` gpd
`r Plan Date 7 Number of Teets 1 Revision Date
Title ,f
Size of Septic Tank Type of S.A.S.
Description of Soil �.
Nature of Repairs or Alterations(Answer when applicable) -
a
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Bo 8 o Health.
Si ed Date
Application Approved by Date ?Ni0r3
4
Application Disapproved by r Date ;
for the following reasons
Permit No.70(75 29-3 Date Issued -2 17 1Z013
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFF�Y,that the On-site Sewage Disposal system Constructed( ) Repaired( � Upgraded( )
Abandoned( )by 9:J f X ui q/�i-+ i on
at �(7t Gt fl D C1( S fU(�� �,{445een constructed in accordance � f2
t
with the p�oHis)ions of Title 5 and the for Disposal System Construction Permit No.2033-Zq? dated �
Z
Installer �< () cl Designer —Do w nQ
/#bedrooms ,� � Approved design flow 3 'Y„ gpd
The issuance of this permit shall t be construed as a guarantee that the system will r nasdesigned. [ U
Date 1 Inspector
-. -----No.--------------------------------------------------------------------- -------
2Lj—� Fee V boo c�J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( ) I Repair( Upgrade( ) Abandon(
t-- )
System located at L� 1 n 1� �n o
IF /
a^
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date - 2Ghj Approved by
FROM :down cape engineering inc 'FAX NO: :15083629880 Jul. 08 2013 09:20PM PI
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(fI!//._,.,du;{'�- 1 1�Qd�B]l:�'� P'. "err
100Mqi1m Sti-eev., H'y"Inwiis,P&A.0-7601.
0fl-h-m: 509-362-1,(-4 Fax, >f13 490-6`104
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Ad flreafs:
Address:
ex('d\ICL+l 0
On. -.27P4 125 ISSIlf-d is-jxiuiif to in.,7t;ill a
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ID 027-112,._.._. .._.... __ . _ ..__._.a._..__ __. w___. __ Developer;___.
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Location 141 SPUR LANE Pri 140
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City SHARON State';MA Zip Country
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Acres Use'Single Fa MDL-01 Zoning RF TM Nghbd r0105 _
Topography Level Road l,Paved
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Building 1 of 1
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Living 1102 TM As h/F GIs/Cm Type Built Struct Wall
Area' Cover p __ _/ _..p I YPC None
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_.___�._ Heat -- ...._.._.w_�__ Found-
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7/10/2013
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, U
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew Gilfoy
use the return Name of Inspector
key.
B B Excavation,lnc.
ry Company Name
14 Teaberry Lane
Company Address
Forestdale MA 02644
City/Town State Zip Code
508-477-0653 S 113640
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
` Title 5(310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
X 5/13/13
Inspector's Pignature 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.
�11311
3
t5ins•11/10 Title 5 Official InUV,,urface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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•11/10 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
M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
:a Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence,of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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 Y2 day flow
t5ins•11/10 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
M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
v Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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?
❑ M 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [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 d n/a
9 ( Y g (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: April 2013
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•11/10 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
;M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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:
1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >100 from wellfeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
Depth below grade: f 6t
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:
5"
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cost.)
Distance from top of sludge to bottom of outlet tee or baffle
33"
- 311
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
16"
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 appears to be structurally sound. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts v
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box needs to be replaced.Also, shows signs of hydraulic failure
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.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
2 flow diffusers
❑ 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 is in hydraulic failure and must be replaced
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a
M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is Marstons Mills MA 02648 5/13/13
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
' Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 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
q� 141 :Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 5/13/13
page. Cityrrown 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
El drawing attached separately
A2= 28' � "
-82_ 19 i
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
J Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5/13/13
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: >20'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
gw 26' below grade
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
• Official Inspection Form
Title 5 p
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 141 Spur Lane
Property Address
Schneider Family Trust
Owner Owner's Name
information is MA 02648 5/13/13
required for every Marstons Mills
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
13 - /o,
Town of Barnstable P#
CF tXE
�y� c Department of Regulatory Services
BARNSTABM ' Public Health Division Date �b IL-3
y MASS. g
039. 200 Main Street,Hyannis MA 02601
Date Scheduled / 06ime i Fee Pd. 04 - o a
Soial uitability Assessment for S Dispos a
Performed By: Witnessed By:
LOCATION & GENERAL INFORMATION _
Location Address / I S Owner's Name e
rcA ,Ay
G,tL v," /
n.0 �Q /rnjK Address \
Assessor's Map/Parcel: a � i D ",V I Engineer's Name W 0 tv, e
NEW CONSTRUCTION REPAIR Telephone# 5 08)36d
Land Use Slopes(%) z 76 Surface Stones - _
Distances from: Open Water Body ft Possible Wet Area �,1! ft Drinking Water Well ft
Drainage Way NIA- ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
w�u
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;i M1 13`�1 t N v
>. . . u�
Parent material(geologic) Gk7_ws4S�j Depth to Bedrock >3Ga /
Depth to Groundwater: Standing Water in Hole: t Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOIL SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: N in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustm t ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
T PERCOLATION TEST Date Time %J =.
Observation
Hole# Time at 9"
Depth of Pere Time at 6"
Start Pre-soak Time @ Time(9"-6") 0 a�
End Pre-soak A,v i�
Rate Min./Inch '�l �d
VVt
Site Suitability Assessment: Site Passed X, Site Failed: Additional Testing Needed(Y/N) /V
Original: Public Health Division Observation Hole Data To Be Completed on Back--- -
**If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
QASEPTIC\PERCFORM.DOC
e - R
DEEP OBSERVATION HOLE LOG: : Hole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
// Consistency.%Graven
Z-15 -
- /o Y2 4 X/
Qy�u�4
DEEROBSERVATION HOLE LOGY Hole# -- w;
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
0-8 A LS /a Y23/3
8—2u 6 S /U ykcG l
gv-&d c cs itl yl2 7/y
IJ6 w
DEEP OBSERVATION HOLE LOG Hole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
t� :DEER OBSERVATION HOLE LOG „ Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
Flood Insurance Rate Mali
Above 500 year flood boundary No Yes
Within 500 year boundary No— Yes
Within 100 year flood boundary No Yes
Death 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? ��
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017. ,,pp
Signature Date '1/xi3
Q:\SEPTIC\PERCFORM.DOC
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I N S T A LLER'S NAME i ADDRESS
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B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �� /�
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No........���1.�8.l e. • ._ -,:. Fxs.f�..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........� ...................OF.. '`.?..��.��T
S Appliration for Disposal Works Tonstrttrtuan ramit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
.....-45?r $S Lc► Y3.Y_....................................s �n u/Z �./�l: - ' y'� f t�t,J.........................
-- --
Location-Address or Lot No.
...........,?�c�,_..._.S.A CD Q ------------------•-------...... ..... -..........................................
Ow er Address
a ........•--•--_---•--------••••--•-•••.....................•....-----•--•-••._.............------ ...---••----••-•---••..............._--•-••-••---...._..._........._.......-----••-----......---•-
Installer Address
Type of Building 3 Size Lot.Zv)Zc2e.....Sq. feet
., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (Nu)
aOther—Type
of Building ............................ No. of persons........................... Showers ( ) — Cafeteria
QOther fixtures ----------------------------•-•----....-----------•--....------------•-----••-----•---._.._...---------............. ........_.........
W Design Flow..........._.'r.......................gallons per person per day. Total daily flow............ 3v.......... .....gallons.
WSeptic Tank—Liquid capacity!0P..gallons Length..... :5.... Width:.`',:.-s.. Diameter................ Depth_..'g- _..
x Disposal Trench—No. .....l............. Width......8.......... Total Length....._z k....._ Total leaching area.A4_3........sq. ft.
3 Seepage Pit No--------------------- Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ' ) Dosing tank ( )
Percolation Test Results PerformedC .l .!�? .._...
Test Pit No. 1.L_�-.....minutes per inch Depth of Test Pit--12............. Depth to ground water....tl!ME...FNO
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Pr ---------------------------•-------------------
•----------------------------
----------•-------- -----•---.........
O Description of Soil.......... �£.e4/��•--••-Gof►/?5.......... �}/Yo........ C. ? Ni ....--•................•-----•
V ..............••---..._...........•-•-----•-•••........-••--••-----••-•---•-.......---••••-••••--------•---•••--••------•---•---•••-••-----•-•---•••......•----•..........----•-•-_•-----•-•.............
W
UNature 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,ITL; 5 of the State Sanitary Code— The undersign urther agrees not to place the system in
operation itit Certificatp. Compliance has been 's ed/by t oa o iealth.
Signed ✓ .� _ .... . ....................................... .....7._- ..�`:
.
f Date
Application Approved By...................... ........ '. ,// -
•••............................. ....._..............Date------......•.
Application Disapproved for the following reasons:-- ---•••-------•-•---•-•-•--•--•-•--••...••-•...............•_---•---••--••---•-•-••............-•-.........._
...••-••••--••••.............................•--•••---.-----•-•••--..........-•-••--•-----•••--•-•---.....--•....•---••-••- .._.. ----------------•-•------- ....
Date
PermitNo.......................................................... Issued......................................................-
Date
No.......g L. f S a*1'; .`,. ' Fms.�.,.................._.
L 6 THE,COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
oI�JN
"IJ
f ..... ......... ....................OF...... �..N.:: .A.-Y3C. ,
. _
Appliration for Uisposttl Marks Tonstrnrtion trrutit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
......L -t c.: `GS W Rk�Y3`( ..T1..-TC'...S....
LocationU./Z ............... l..' l:�1..1.1 1�.1 - -•-
--..-_....--................. -••l --Address or Lot No.
Ac u c J C�-\ am _�"' ��ASI IRi�`� E UIL�I k)471�
................ .. ___ ......•....._......_...........
Ow er Address
........................... -----.-•----------------•-.--------------- -••••-••-•=.......................................................................................
Installer o-Address
Type of Building 1 n' Size �.....Sq. feet
.-� Dwelling—No. of Bedrooms..._.._...`.......2........ ..........Expansion Attic ( ) Garbage Grinder 6)u)
`-� Other—a Type of Building•--------- ................ No. of persons............................ Showers
( ) — Cafeteria ( )
dOther fixtures -----------•----------------•-------.----------.....--•-----•-•---------- ------------------•-----------........••-• ..............
W Design Flow............5. .......................gallons per person per day. Total daily flow.........._ v......................gallons.
WSeptic Tank—Liquid capacity Q¢ ..gallons Length-----�:.5-..... Width_.`J'_:-5.._ Diameter:............... Depth...'`V-0....
x Disposal Trench—No.....t............. Width..... .......... Total Length....... ._8s._...... Total leaching area.%t 9.3........sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) /
'~ Percolation Test Results Performed by T'....��..%� .....N ��..._.•............................ Date? �! ��.._........._.....
a
Test Pit No. 1. .z-.....minutes per inch Depth of Test Pit...; ............. Depth to ground water.__PQ f_-•rNo
(sr Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•----------------------------------------•-•----••-•-----.......----.......••-•--•••--•......----•-•-•........._......--•--••-•...........--•---.......---...
O Description of Soil.........Cis ArJ...._.. S�tni �12i'�G
x -----.....- • ............................•••.......•-•••-.............
V .............................................•••••••---•--••-•---•.....-•-••-•••-••••--•••••------••••••••••--••-•-•••----••••-•••••••-•--•-•••---••-•••......-•••••..... ----.......---...••..••.
W
VNature 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 T I T LZ 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation ntil Certificate ompliance has been,issued by t e board o. iealth.
CJ3°1s� Signed....... _ill ,l c_ - .......................•-------••---.. .......................' / ..
tr Application Approved IIY Date
'- --1 Z-•-•---•.............. ........................................
Date
Application Disapproved for the following reasons--- ---------------•---•---------------•---------.....-------•-----------------...-----.._......._...-•--•------
.............................••-••--•-•••-••-•-••-•••-••••-•--•--••••...•--•-....-••-........•--•-••......-••--•••--•.....•--••••-••••••••-•--••-•-••••-•••-••-••••---•-••-••••-••••••.................
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH d
..........................................OF -.......................................:..................
Trrtifutttr of faontplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by - ------------------------------•--•------------ ------------- - - ..--
lat 7er ---• .4..I
has been installed in accordance with the provisions of TITLE,:,1_,j of The State Sanitary Codek,as described in the
application for Disposal Works Construction Permit No.......... i s '..... dated................M..............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF Z It .
DATE................................................ - -------- Inspector------------- ------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
8% gSU ..........................................OF....--........---...............-•---•-•.....--•-•--•--•••.
No.- ................. FEE--.r .............
Disposal Works Tonstrnrtion f rrntif
Permissionis hereby granted.................... • 7---------------------------------....................................................................
to Construct ( or Repair (/,/' an Individual Sewage Disposal Syst m
........... . ........•-•-••at
_L"_JY...f "`-Z...--v L --•------•=-. .----_---"-=---..........................-..............I.........
Street
as shown on the application for Disposal Works Construction mit No.___....._.t<_._..._ Dated..........................................
. !
lloard of Health
DATEw---��`�--•....................•-••••-••••----•.
77
Log Number: Bottle # D131 Date:'g 19.424
BARNSTAEFILE COUNTY HEALTH DEPARTMENT
.'t SUPERIOR COURT HOUSE
BARNSTABLE, MASSACHUSETTS 02630
wss DRINKING WATER LABORATORY ANALYSIS PRONE: 362-2511
EXT. 331
Client: John.Shields Collector: . Edward P. -Meehan
Mailing Address: Main St., Affiliation: Meehan Well Drilling
---- -
Centerville,e, MA 02632 Time & Date of
Collection: 9/1.7/84. 12:15. p.m.
Telephone: - 86 Type of Supply: well water
Sample Location: Lot 85, Spur Lane Well Depth: 53'
Marstons Mills Date of Analysis: . :g/1:8/84
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS
Total Coliform Bacteria/100 ml 0 0
H 5.5
Conductivity (micromhos/cm) 63 500.0
Iron m) <0 .05 0.3
Nitrate-Nitrogen ( m) 1 .18 10.0
Sodium ( m) 20.0
I : xx Water sample meets the recommended limits for drinking of all above tested parameters.
II . Based only on results of the parameters tested for this sample, the water is
suitable for drinking but may present the problems checked below:
A. Water sample has higher than average levels of Nitrate. ' -Future monitoring' is
recommended. (2-3 times per year) to establish-any upward trends.-
B. The low pH of the water may shorten the useful life of the house's plumbing.
C. Water, may`present aesthetic problems (taste, odor, staining) due to
I
D. Water sample has high levels-of sodium. Persons on low sodium diets should
'consult their doctor.
III. Due to one or more of the reasons checked below, this water sample is unfit for
human consumption: A. High Bacteria B. High Nitrates
REMARKS: ,
CC: Barnstable Board of Health d �
CC: Meehan Well Drilling
Laborat Director
7/17/84
Ex"lanatton of test Results
Total Coliform Bacteria
Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become
contaminated from malfunctioning septic systems,cesspools and surface runoff. A total coliform count of zero
indicates that your water.supply is safe and'approved for human consumption. A total coliform count of greater
than zero is most often,the.result of accidental contamination.of the sample bottle through improper sampling
methods. For this reason, it would be advisable to retest any well water that is not approved.
pH
III 1 h number 7 is neutral less than 7
pH is the measure of acidity or alkalinity of the water. On the pH scale, t e ,
is acidic and more than 2 is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5
Conductivity
Conductivity is a.measure of the dissolved salts in solution. Amounts in excess of 500 micromhos'^m are
generally considered unacceptable and may have a laxative effect upon users.,
iron
The presence of ironJn water in concentration of .3 ppm or greater may: give the water a bittersweet
astringent taste, cause an,unpleasant odor, often gives the water a brownish cold_rand cause staining of laundry
and porcelain,. The average concentration,'of�iron in Cape Cod's water is .2='.6 ppm. Although the presence of
iron in water may, cause the-:problems�listed.above, it is not considered, deleterious to.health. Iron may be
removed by use of an iron,removal system
Nitrate-nitrogen
T
The Massachusetts Drinking:Water RegulaCia�s have set a maximum,contaminant level for nitrates at 10
ppm. Excessive.concentra(ions'may catise.:methemoglohinemia (an infant disease}and have been suggested to
form potentially carcinogenic nitrosamines. Contamination sources.include fertilizers, cesspools and industrial
wastes.
t:opper
Due to the.acidic nature of the water.on Cape Cod, copper tends to leach from pipes. This normally does:
not present a health hazard;.however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a
bluish green stain on porcelain fixtures.
Sodium
A concentration of.sodium over 20 ppm is only of concern to people who are on a low sodium diet. If the
water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source
of drinking water or contact their doctor to determine if consuming the water is advisable. Concentrations
exceeding 50 ppm indicate that there,may:be ocean water or road salt runoff water getting into the well.
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w.i.. }33 .. 'F•e. r♦'. �1s .�..N..., ., J:.:;;.,. � ;Ja' ,a , :,.. i• +'. Ye. .'f .. r{r raw , ,i •t* ,ir, ,. _ ,a
0,
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x. _. .. _ _ ..e, _,._�,w',..... ,..i.._�..._-.•,..�'._._ — - ...._.....
e..e .xax. .�..,d^-� ._.e.•,,..,.,.,......E„e�..t,_.,:d.F.er€r,.:.,,d:,s,.:rra,..•,+;..a•.-N,.:._.,.::�.+K...:;.L.,3,a :._.:- :c._.:.. .._: ... .._ � ...,.....,w. ♦1._.:.,e--I.;:.-:.a..:L�;. _.__...ca ., ..,.,_ A.:,3. - ..._..`_.._..1'.e:�.:i.:...,.- ,1' - r.1�.�._.,.. _._..+..-.a._.ea. 1 ,. , .+., .._......,. u . r
ALL STE
LL
SYSTEM PROFILE MARK ED WITHC MAGNETIC TTAPEAOR BE
NOT TO SCALE COMPARABLE MEANS FOR FUTURE LOCATION.
PROVIDE MIN. 20" DIAM. WATERTIGHT ) NOTES
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE rr o- o �°
TOP FOUND. EL. 78.15' 1. DATUM IS APPROX. NGVD
\ MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 78.0'- 79.0'1 2. MUNICIPAL WATER IS NOT AVAILABLE ¢ �� �°j
PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. °
PRECAST H-10 H-20 D'BOX
RISERS (TYP.) 4"0SCH40 PVC 4. DESIGN LOADING FOR D'BOX TO BE H-20
2 75.8 PIPES LEVEL 1ST 2' 2" DOUBLE-WASHED PE}STON n N
' � OR GEOTEXTILE FABRIC 5. PIPE JOINTS TO BE MADE WATERTIGHT. eb ` {
10" EXISTING 74.5
14" 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE P ,IS
a ' TEE SEPTIC TANK** TEE 74.4t*'79'
° ° 0 °'' ° 0 ° ° ° ° ° ° ° ° WITH 310 CMR 15.000 (TITLE 5.) cus Pond p2j
000°0°0°0°0°0°0°0°0°0°0°°°0°0°°°000°0°01 pp0°0°00O 0O°0°O°O0O°00
° ° ° ° 73.99 °°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° °°°°°°° O°°°°°°°°°°°°° s
°0°°°°°O °O°O°°°0°°°°°0°°°°°0°°°°°0°O°°°°90°°O°°0 0°O°O°O O°O°O°O°O°O°00 O e
GAS BAFFLE ��°°°°°° 0°000°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°° °0°0°0 °°0°0°000 71 84' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND �� Lo
° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° °° ° ° ° ° ° ° ° ° ° ° NOT TO BE USED FOR LOT LINE STAKING OR ANY74. 74.02' 4" PVC SET AT .005' ''SLOPE _ OTHER PURPOSE.
6' SUMP
ON 6" DOUBLE WASHED 3/4". • 1 1/2" STONE o
12" MIN. INT. DIM. 2 LEACH TRENCHbiS 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
32' L x 3' W x 2' D. 3.34'*** 28'f 9• COMPONENTS NOT TO BE BACKFILLED OR
6" CRUSHED STONE OR MECHANICAL
CONCEALED WITHOUT INSPECTION BY BOARD OF
COMPACTION. (15.221 [21) HEALTH AND PERMISSION OBTAINED FROM BOARD
OF HEALTH.
( 1 SLOPE) ( 1 % SLOPE) BOT'_OM TEST HOLE 1 68.5' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR
LEACHING ***G-W EXPECTED AT EL. 44'f CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP
FOUNDATION_EXISTING SEPTIC TANK 21 D' BOX 5' VERIFYING THE LOCATION OF ALL UNDERGROUND &
FACILITY INSTALLER TO CONFIRM SUITABLE SOIL FOR OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT MIN. 4' BENEATH SAS AT TIME OF INSTALL. WORK. NOT TO SCALE
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM NTH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 27 PARCEL 112
CONDITIONS IF NOT SUITABLE SHALL BE REMOVED 5' BENEATH AND AROUND THE
PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE SAND.
IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR
BY HEALTH INSPECTOR
PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED sp//� ����
BY THE BOARD OF HEALTH REVISED DURING A PUBLIC V
HEARING HELD ON AUG. 4, 2009 SYSTEM DESIGN:
1) FAILED SYSTEMS ONLY: SAS TO PRIVATE ONSITE WELL -7 S0- - - - - - - - - - - - - - - - - �.8; - -- - - - - - 77.52 GARBAGE DISPOSER IS NOT ALLOWED
SEPARATION DISTANCE VARIANCES, IF LOCATED IN THE SAME
76. 4
GENERAL LOCATION AS THE OLD SAS AND MORE THAN 100 .1 6 A- 1 0 9 : 8 4 ' R-2 0 6 9 . 3 2 '
FEET SEPARATION IS PROPOSED BOTH FROM ON-SITE WELL AND - = 76.30 30.00' '96
DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD
ANY AND ALL WELLS ON ADJACENT AND NEIGHBORING PARCELS. -
3) FAILED SYSTEMS ONLY: SOIL ABSORPTION SYSTEM \\ I USE A 330 GPD DESIGN FLOW
INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW \
GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) \I _ SEPTIC TANK: 330 GPD (2) = 660
AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS - 5 I7
BE LOCATED MORE THAN SIX FEET BELOW GRADE. \ LOT 85 RE-USE 1000 GAL. SEPTIC TANK **
20,202f S.F. 76. 6
o LEACHING: - -
\\F� 176.5 SIDES: 2 2 32 + 3 2 .74 = 207 GPD
[
BOTTOM\\G/ I 2[32 x 3 (.74)1 = 142 GPD
TEST HOLE LOGS 9
\ � � TOTAL: 472 S.F. 349 GPD
\s goo,
ENGINEER: ARNE H. OJALA, PE, SE \ 76. 9 0o USE (2) 32' LONG x 3' WIDE x 2' DEEP
\ LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE
WITNESS: DONNA MIORANDI, RS \ 76.77
DATE: JUNE 19, 2013 \\ ��
PERC. RATE _ < 2 MIN/INCH 79.9
BENCHMARK: USE COR. �
CLASS I SOILS p# 14037 BULKHEAD AT EL. 77.6' \\ 7 .14> �� p q
00 .77.1) od O MA
o \ , 7 ��
ELEV.
ELEV. o 00 APPROVED DATE BOARD OF HEALTH
1 2
0Opp" 78.5 0 79.0' EXIST. DWELL. //� a � 79.79
TOP FNDN. _ �' '78.1
A EL. 78.15' �`
� �
PROP. VENT WITH CHARCOAL FILTER TITLE 5 SITE PLAN
LS AND BUGSCREEN (FINAL PLACEMENT BY �' �� `
10YR 3/3 CONTRACTOR WITH HOMEOWNER 77. 5 OF
8„ CONSULTATION) ✓' r
FILL B "' :.DECK � TH 1 80.71
141 SPUR LANE
cs . 76 MARSTONS MILLS
�__--- -7-7 O _ 77.08
10YR 6/4 ----------- 77.02 � ��8 76 PREPARED FOR
`�°
8" 77.8 20" 77.3' �� N ��� TH 80.66
81.0 B&B EXCAVATION/
C C . 7� �0'1� --- ----- AK SHED 81.32 SCHNEIDER
PERC �� -------- -----
CS CS 78.50 0 //�° f' a JULY 1, 2013
/79.01 �1
1OYR 7/4 10YR 7/4 81.So �-'
off 508-362-4541
y� 131.97 , �SH°FMgss � � 5� fax 508-362-9880
DANIuLA. yGn DANIEL cyG� y I downcape.com
cy0 `o OJALA A.oo. CIVIL ' ; OJAI down cape engilleefing, ift.
502 No.403;0
120" 68.5' 120" 69.0' �o��F�� �� s �� civil engineers
�� '*,
<� oSTE .� 'Al.� E� x.� �. land surveyors
NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 -1'-13
� m`��'"b � ���� �`�V ( 939 Main Street ( R to 6A)
DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
® 9 0 10 20 30 40 50 FEET
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