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HomeMy WebLinkAbout0067 STARLIGHT DRIVE - Health i'67 Starlight Drive Marstons Mills Rt A 100 037 A I I ilk i S ge Per oll" /171 ,oi6i8o q1 o/a yz' 45 Commonwealth of Massachusetts too -OP— Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name / information is required for every Marstons Mills ✓ MA 02648 05/11/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information Su on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. Rivers End Road Co � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. . ❑ Fails ` lee 05/12/2021 Inspector's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and.the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: This 5 bedroom home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding two precast leaching pits with stone. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will ° pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—iWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form: �- F; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « / 67 Starlight Drive V� Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual). 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 55 plus GP Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2020-214,000 gallons were used and in 2019-215,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool I ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ^i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 26"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: H-10 1500 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: A Type: ® leaching pits number: Two ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool , number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � 3 G9# N Zp` 1 Y �\ z 33" l �— Soo, �� I ry 1f R t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 17 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Starlight Drive Property Address Ammad Sheikh Owner Owner's Name information is required for every Marstons Mills MA 02648 05/11/2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 }' 19 r.,,a:='!"� ;`c �;rr�xr;�:t...,.1�'.�.•Yif ��.� r i r`r��''''49;1r:'�SS"tTR•-!j ��f'�''IS0�C S'1 N�,h r,��1114 �r1��}�k����`fh�'� . ,y.ry,� ,'' :�.':"�a7'nJ' t.�q"'� i'`sr';�.�lv�'��•. tip �IS �i>����1'�9�`��..i,�9t1�•Y�;F Ru .r.. .f' r' r � �:< r;;. ,�;:•s�kt:�i;N'Atib���0�1 t�+,.x•5ii,�l,.i.. :r k' r " sla. 21Fc.e. 02648 3 c r ceu Bam tab L.rd..a Cbrt _ 'j'.• 1 s =i I' n .. o Den ri �I Bedroom 30.0' (� Laundry b E m Bath Kitchen Dining Room (61 Bath Q Room o Living Kitche eNe m Family (O Room RoomC Bedroom Bedroom Bedroom Living.Room n N 14.0' 44.o' Interior Not Dr;aWh to SCale Sketch M Apex N VWldow/*' AREA CALCULATIONS SUMMARY LIVING AREA BREAKDOWN. Ma Nam.of Ma stza. Tolab Smakdewn sublolala OLAI Hrat !loot 2200.00 2200.00 FSrrt - 7/.0 a 7t.0 100/.00 - ' 1�.0 21.0 = 30.0 710.60 . it.. z 24.0 314.06 . TOTAL LNAOLE rounded 2200 . 4 Areae Total rounded 12001 .... L. a .�.. j. Janovsky Appraisal Service :. Town of Barnstable Health Inspector FTHE rpm Office Hours "o "ir MRNSTABLE Regulatory Services 8:30-9:30 Thomas F.Geiler,Director 1:00 2:00 STAB J ,0� Public Health Division A AIEo � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 5M8624644'5 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE 1. General Information: Size of Property: Address: S� � '1 �V l' Map l 00 Parcel 03q' Name: 1�y'^`�' `' ��-`� -� Phone#: 6J3-a q q—r'15�3 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? KAD If yes, how many? 'v i 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is connected,to public sewer,skip,,questions#4 through#9.below. . - 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a.•If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at thisproperty. J � Special Conditions: Signed: Date: 12- o Q;/health/wpfiles/amnestyapp u 46t2.,f I F FOR MAIL-IN APPLICATIONS Please,mail a completed application form to the address below. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED APPLICATIONS Our fax number is (508) 790-6304. Please fax a completed application form. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. For further assistance on any item above, call (508) 862-4644 To get an amnesty program septic questionnaire form, click here. To be able to access this form, your computer must have Acrobat Reader. Most computers have Acrobat Reader, and it will usually activate itself automatically. If your computer does not have Acrobat Reader, you can download a copy of it by going to the Adobe website. Back to Main Public Health Division Paize Q;/health/wpfiles/amnestyapp f ♦r{tf i if 1"''yy�.'kf lJ!{T)'r��t i9i��^�y Mhy �A��"}7}�){♦j '"�'f fAdb ..... a •. ti ;., .., k��cN� ���U�l•t9�t9 ;�.�':�� 6onowef ofo r Muha mad& a ra a Addnu sue. zip code 02648 r c Bam tabMA ';3 Lendx or ctom Assurance Mortgage Com.of Am. Al 5k 11 28.0' ' 30.0'.. N Den 'I Bedroom Laundry o m Bath Kitchen Dining Room m Bath Q Room M o Living K tche ette m Family Room Room Bedroom Bedroom Bedroom Living Room n o 0' fV 14. 44.0' Interior Not DraWn to Scale Sketch by Apex ry wnd—o ' . MA RY LI VING ARE A BREAKDOWN AREA CALCULATIONS SUM anakdewn subtotde Am Nrmr or M. str.. Totals Hra 1 loor ]200.00 ]]00.00 rim 71o6r Ot.A] 001.00 1.0 1 2.0 x 14.0 7r.00 i ]A.0 x 10.0 710.00 p 11.0 x 2/.0 1/4.00 TOTAL LIVABLE rounded 2200 4 Areas Total rounded 22001 to t � •i Janovsky Appraisal Service •. it'd, .. --. OKMONINT ALTH OF K S ACHUSET 'S EXECUTNE OFFICE OF ENVIRON-MENTT-U AFFAIRS i DEPARTMENT OF EI�'VIRONiViE?�'T_�L PROTECTION s N sV y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: g 7 ►& } t\d'e— q Owner's Name: Ca Owner's Address: L7 E±g&r4 �t'JL Date of Inspection: ml �3 p, Name of Inspector:Splease print) e, Company Name: A&44,14 t IL i rovj vn e,n t K SpCci w i-S Mailing Address: &IX & O4-6q Telephone Number:_S-D,-3jk5 -7 6 C>8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 2 Date: The system inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This in does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/Z000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DIISPOSAL`SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 7 5- o.4rk � C—duf Owner r1aL V11 Bate of Inspection: a- l3� OBI Inspection Summary: Check A,B,C,B or E/ALWAYS complete all of Section B 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 will pass. Answer yes,no or not determined(Y,N,ND)in the for the following state .If"not determined"please . A explain. The septic tank is metal and over 20 years old*or the sep ' (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltrasion or ure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as` oved by the Board of Health. *A metal septic tank will pass inspection if it is stru Ily sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old i vailable. ND explain. Observation of sewage bac or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a b en,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)amzeplaced obstruction is removed distribution box is leveled or replaced ND explain: Th ystem required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass in lion if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORD PART A CERTIFICATION(continued) Property Address: 7 S-E&v 6 J-P, Owner: t"a, G► ► Date of Inspection: b� 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 a 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. 03(l)(b)that the system is not functioning in a manner which will protect public health,safety an he 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 It marsh Z. System will fail unless the Board of Health(and Public Wat Supplier,if any)determines that the system is functioning in a manner that protects the public he h,safety and environment: _ The system has aseptic tank and soil absorptions em(SAS)and the SAS is within. 100 feet of a surface water supply or tributary to a surface water su ly. — The system has a septic tank and SAS and t SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method ed to determine distance "This system passes if the well ater analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic c mpounds indicates that the well is free from pollution from that facility and the presence of ammonia n• ogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other . failure criteria are trigger A copy of the analysis must be attached to this form. 3. Other: 3 t Page 4 of l l OFFICIAL INSPECTION FORM.—NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART - CERZTIFICATION(continued) Property Address: 9 7 5 Gox k z c,\*%i Dr-%44 Owner:A�C`CG, _ Date of Inspection: y D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for awl 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 Y Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 0( Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. y 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.IThis system passes if the well water analysis, performed at a DEP certified Laboratory;for coliform bacteria and volatile organic.compomads indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal-to or less than 5 ppm,provided that no other,failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve.a facility w' design now of 10,000 gpd to 15,000 gpd. t You must indicate either"yes"or"no"to each of the foil (The following criteria apply to large systems in.ad ' n to the criteria above) yes no the system is within 400 feet a surface drinking water supply the system is within feet of a tributary to a surface drinking water supply the system is 1 ated in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of ublic water supply well If you have ans ed"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Secti D above the large system has failed.The owner or operator of any large system considered a, significant eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.Th system owner should contact the appropriate regional office of the Department- 4 Page 5 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKI.:IST . Property Address: 7 56 c `r\+ J/Ir-,v-c c Owner: A b s-a 0►4\. Date of Inspection: 13 JOcO 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 AHave large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) 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? oft _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? t _ Was the facility owner(and occupants if different from owner)provided with information on the proper mtenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y no s Existing information.For example,a plan at the Board of Health. x _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: � ,G1'� lA-O Owner: t"U Date of Inspection: OC- FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):__e Number of bedrooms(actual): S DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x n of bedrooms):1 Number of current residents: 3 Does residence have a garbage grinder(yes or no):�CS Is laundry on a separate sewage system(yes or no): UO[if yes separate inspection required] Laundry system inspected(yes or no):IJ� Seasonal use: (yes or no): IJ'O Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Il Last date of occupancy: C -t 4 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15 203): apd Basis of design flow(seats/persons/sgft,etc. Grease trap present(yes or no):_ Industrial waste holding tank presen es or no):_ Non-sanitary waste discharged to a Title 5 system(yes or no):_ Water meter readings,if avail e: Last date of occupancy/use, OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): A 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 ob_tained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all com onents date costa ed(if known)annd,,source of information: --« Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM(INFORMATION(continued) Property Address: mo-C-6ift ;t�S Owner: 16 C'Gu Date of Inspection: b _ BUILDING SEWER(locate on site plan) . Depth below grade: T Materials of construction:_cast iron K40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) r Depth below grade: _ Material of construction: concrete_metal_fiberglass polyethylene other(explain) If_tank is metal List age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1$Db 9(X Sludge depth: -1 '` Distance from top of sludge to bottom of outlet tee or baffle: 3a Scum thickness:T�" - r Distance from top of scum to top of outlet tee or baffle:—6 Distance from bottom of scum to bottom of outlet tee oafYle: t `{ How were dimensions determined: jY\ ,e&Aor-ecX- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relatej to outlet invert,evidence of leakage,etc. - ` 1 kG c'- a Q K� W kacv- C�. dk J GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete metal fi glass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of o et tee or baffle: Distance from bottom of scum to ttom of outlet tee or baffle: Date of last pumping: Comments(on pumping re endations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet rove evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: fs 7_g{,c.r Skt M v< M wc� Owner;� •Gt`nG��l1\ Date of Inspection: TIGHT or(HOLDING TANK: (tank must pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(expiain): Dimensions: Capacity: allons Design Flow: gallons/day Alarm present(yes or no): Alarm level: in working order(yes or no): Date of last pumping: Comments(conditio of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Q J QM 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.): *1—.A by X -e JC` GCv �.�`{ W o 6 X! $A- D"r ty.C \KA PUMP CHAMBER: (locate on site Pumps in working order(yes or Alarms in working order(ye r no): Comments(note conditio of pump chamber,condition of pumps and appurtenances,etc.): i i { L . g Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSUPFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 J,, wr Owner p Date of Inspection: C' SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number. eZ leaching chambers,number_ leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition.of vegetation. 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 eroundw er inflow(yes or no): Comments(note c dition 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 conditi of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):, 9 y Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION(continued) Property Address 7 � �a,h- � e Owner: Date of Inspection- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet_Locate where public water supply enters the building. G� �r i i I i - j I 1 i j. i { in ' Page l l of 11 OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 7 Joj` �C c (�S Owner: Date of Inspection: SITE E Slope N1VI 0 Surface water Check cellar Shallow wells 0 Estimated depth to ground water_,&Orfeet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water glevation: cc o\yqA er . i i lI 41 1 I CERTIFY THAT THIS SURVEY AND PLAN WERE MADE IN ACCORDANCE WITH THE PROCEDURAL AND TECHNICAL STANDARDS FOR THE PRACTICE OF LAND SURVEYING IN LOT 52 COMMONWEALTH OF MA ACHUSETTS PAUL A. MERIT' f ( AT £ A.M. N53 27'17"W 3w �? 100/27-1 <7;r 136.8' I ' I I ' I ' I ' Ill ' I ' I ' I ' 111 ', III ' I ' I ' I ' I ' I ' I ' Il O CtiJllll IIIIIIIIIII A M. p f III I I I I I I 100127-2 cZi � i l l l l l l l l III ti II11111111111111111 652' '12, 1' IYI � I � I � I � cc�` IIIIIIII � O � � ~ III111111 �9 16.0' 111111111111 15.5' ' 1CNI ' IIIIIIII 9.9'Cl- o �� d; lllll A.M. rh I I I 100128 LOT 118 1 ' 115.8' S53°27'17T GRAPHIC SCALE LOT 50 20 -0 10 20 40 80 ( IN FEET ) 1 inch = 20 ft. Bhp eNS TABLE �11 OLD FAL RD. q J� LOCUS / 160.00' _ ROUTE s c 8 ' LOCUS MAP ASSESSORS MAP.•100 ,LOT 37 PLAN REF- 29500C ZONING: "RF" �I FLOOD ZONE- 'C" ti COMM.. PANEL# ' 56.3' 250001 0015 C '.6' � �i DATED.• 8119185 0 VERLA Y DISTRICT- "GP" ti PLOT PLAN ' LOT 51 OF LAND �o AREA— LOCA TED AT 20,800fS F 67 STARLIGHT DRIVE MARSTONS MILLS,- MASS. PREPARED FOR MARY ABRAHAM JANUARY 30, 2002 160. 00' YANKEE SURVEY CONSULTANTS UNIT 4 40B INDUSTRY ROAD P.0. BOX 265 MARSTONS MILLS, MASS. 02648 TEL 428-0055 FAX 420-5553 Jf 53008 DCB TOWN OF BARNSTABLE I LOCATION 5-,lXe4 SEWAGE # 72- s �13 VILLAGE��sr�� cc�r�lS` ASSESSOR'S MAP & LOTC�� INSTALLER'S NAME & PHONE NO. CV ,k/ 79wO yf/ SEPTIC TANK CAPACITY T 7'e9 v srv6 LEACHING FACILITY:(type) ArACc-4s7- (size) 10a a.-I&Q NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER PvG/C _J BUILDER OR OWNER DATE PERMIT ISSUED: 7,///g?, DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t G9� a� 33' 4� o 5'I aV✓ too FEE.. ®_............... THE COMMON WEALTH OF MASSACHUSETTS BOARD OF HEALTH - TOWN OF BARNSTABLE APPROVED enment Appliration fur Uhip0bal larks Tons Application is hereby made for a Permit to.agonstuct ( ) or Repair (VI"'an In vidual Sewage Dish "'- System at: .... .... r A �t 1�T._..p�.._._...#4_4'fS.TQ.A.mom Us............................................... =-= -.-.------------.-------•-------- Location- dress or Lot No.. F" tyd , ._.S�as1i �'? x .....l ?.Ra4 •9,✓1.... ........... ................................................................................................. O ner Address / a !�RkJ.......0._... i sSl.:tiz, -------------------- �.?.. �z�....�_�s -t�cr------- o�-f'�i Installer Address 4� Type of Building � Size Lot___________________________S q. feet Dwelling—No. of Bedrooms........... ,,'-,U1E.....................Expansion Attic ( ) Garbage Grinder ( ) 'PL4_l Other—T e of Building No. of persons------------_............... Showers — Cafeteria 04 Other fixtures ...................................... W Design Flow.............. /__Q.......................gallons per person per day. Total daily flow___---__-__-__T S.D....._.........._gallons. WSeptic Tank—Liquid capacityJ_5b'.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of. Test Pit-------------------- Depth to ground water------------------------ GL, Test Pit No. 2................minutes per inch Depth of Test Pit__-______---__.__--- Depth to ground water........................ -------------•----------------------------•-----•---•-----------------------------•-••............-•......................................................... 0 Description of Soil........................................................................................................................................................................ W ------------------------------------------------------------------------------ -----------------------------------------------------------------------------------------------------------------•------- VNature of Repairs or Alterations—Answer when ..61 j;r,arh4.....�sS�oCz_..a�_S ....... ---p...Boi-........7,�..A......��Q�.,G�i4 �f� 3..-.s � AM-C';'Id................................................................ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard of health. q Signed . . .............. -----.--- - 1 1 19 2 Dt Application Approved By ---------------------------------------------------------------------------------------------------------------- --- •.. ......................... ........................................ Application Disapproved for the following reasons- ------------------------------------------------------------------------- -------- .............................................. ----- --------------------------------- .................. ----------- I Date /Y3 Permit No. ... Issued -- -------------------------- Date o �3 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I /F TOWN OF BARNSTABLE Appliration for Dispasal WorksChun rnij rmi - - / - Application is hereby made for a Permit to Construct or Repair a Inch; Sewage Disposal System at: A.4 ...4.4 ............................... .......................................... ................ . . Location A; . .. A . _ de s..,/ .... . or E;K0 .............. ........................................................ Ow per Add 7 e.Z ............. X------------------------------------- .....o..:72i,)J-----&.k .. . ........ ..... Installer Address Type of Building Size Lot-_-------------------------Sq. feet U 5.�.�.....................Expansion Attic Garbage Grinder ( ) Dwelling—No. of Bedrooms........... 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures .................................................................................................................................................... Design Flow............../Jo......................gallons per person per day. Total daily flow..............•._5-.570.................gallons. 1:4 Septic Tank—Liquid capacity-J-Vactgallons Length-----------_--- Width--_------------ Diameter- -------------- Depth................. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter..............__..... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. I................minutes per inch Depth of Test Pit........._.._._..... Depth to ground water..___.._...._._....____. 44 Test Pit No. 2................minutes per inch Depth of Test Pit--____--_._--_-___-- Depth to ground water....._..._..........___. P4 ............................................................................................................................... ------------- . - .............. 0 Description of Soil.......................................................................................................................................................I............... ..................................................................................................................................................................... U ------------------------------------ .......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable----14, 5-4 0 ..........77,,2,n......./Ansi...�4 ... .................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal.5ystedi-iii-accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard of health. - I Signed .......A.AA'A�tAAj.... ........... ......9 f_1 j 2. Dat .... ......Application Approved By ____----------------------------- .......-----------------------------------------.......... ...............­ --------......... .............. Dare Application Disapproved for the following reasons: .........................................................................................................._------------------------ �..-.�..-.. .--- Date Permit No. ------- I---------------------- Issued .......... ...Date - ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (9jertifirate of Tompliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( by..................................................................................R .......kiA.51.4)..ct----------------------------------------__............................................................... Installer at .............................................................C7.) ............... 66.....AAi'U_��.............................................. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated _............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................7...... Inspector ...... ........................... .......... • ---­­---------- Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE... 0... Disposal Marko Tonotrudiatt "prrutit Permission is hereby granted............I! PRIA.J...... .................................................................................... to Construct or Repair an Individual Sewage Disposal System -:27,40 4T..../)4.........at No......................................... ................��'Q..... .......... ........................... Street as shown on the applicati n for Disposal Works Construction Permit ated .............0 ...... .... Board of Health DATE--------------- ..... ../ ............................. FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS MM DD yyyy ❑Delete NFIRS -1 101920 . U 011 1 151 1 2006 13 106-000014" 000 ❑C1ange Basic FDID * State* Incident Date * Station Incident Number * Exposure * ONO Activity Check this box to Indicate that the address for this incident is provided on the Wildland Fire Census Tract I I Location* ❑Module In Section B "Alternative Location Specification". Use only for Wildland fires. ®street address 67 " STARLIGHT DR ❑InterSeCtion* Number/Milepost Prefix Street or Highway Street Type Suffix Min front of �MARSTONS MILLS I �J 102648 �71 ❑Rear of U State. Zip Code. . Apt./Suite/Room �City ❑Adjacent to ❑Directions cross street or directions, .s a licable Incident Type * El Date & Times Midnight is 0000 E2 Shift & Alarms 13 (Cooking fire, confined to I Check boxes if Month Day Year Hr Min:Sec Local option dates are the t�' I :ident Type same as Alarm ALARM always required 121 " COM32 Aid Given or Received* Date. Alarm * I oil 1 151 1 2006 103':51:44 Plitt or Alarms District Platoon ARRIVAL required, unless canceled or did not arrive ❑Mutual aid received 101921 11 J ❑ Arrival * 1 011 1 151 120061103:57:21 I E3 QAutomatic aid reCV. Their FDID Their { State CONTROLLED Optional, Except for wildland fires Special Studies ❑Mutual aid given I []Automatic aid given I � ❑ Controlled " " �I I Local option LAST UNIT CLEARED, required except for wildland fires ❑Other aid given Their ❑None Incident Number ❑ Last Unit 01 15 2006 04:35.40 Studyl ID# 1 Study al Valueu u u�u� Actions. Taken * Gi Resources * G2 Estimated Dollar Losses & Values ElCheck this box and skip this LOSSES: Required for all fires if known. Optional section if an Apparatus or for non fires. 32 lProvide-basic life I Personnel form is used. None Apparatus Personnel Property $1 1 , 1 000 ,1 000 ❑ Primary Action Taken (1) Suppression U 0013 Contents $1 0001 ,1 000 ❑ 86 Investigate f Additional Action,Taken (2) EMS �J U PRE-INCIDENT VALUE: Optional U I I Other 0006 Property $1 , 000 ,1 000 ❑ Additional Action Taken (3) El include box if resource counts include aid received resources. contents $ 000 , 000 ❑ .)mpleted Modules Hl*Casualties❑None H3 Hazardous Materials Release I Mixed Use Property (Fire-2 Deaths Injuries N ❑None NN Not Mixed Fire 10 Assembly use Structure-3 I I I I 1 ❑Natural Gas: sle..leak, ne evaeatien or HaaMat action, 20 I Civil Fire Cas.-4 2 Education use I Service � L_J Medical use []Propane gas: <21 ib. tank �a,in home BBQ grill) 33 (Fire Civilian Serv. Cas.-5 L_J U 3 ❑Gasoline: vehicle feel tank or portable container 40 Residential use 51 Row of stores EMS-6 �.� 4 Kerosene: feel burning equipment or portable storage Detector 53 Enclosed mall IHazMat-7 r Required for Confined Fires. 5 ❑Diesel fuel/fuel Oil:vahiele feel tantc or Portable 58 Bus. & Residential IWildland Fire-8 6 ❑Household solvents: home/office spill, cleanup only 59 Office use 1❑Detector alerted occupants 60 (Apparatus-9 7 ❑Motor oil: from engine or portable container Industrial use 65 (Personnel-10 2E]Detector did not alert them 8 ❑paint: from paint—a totaling<'55 gallons Military use use (Arson-11 U❑Unknown 0 ❑Other: special Ramat actions required or spill>55gal., 00 d0ther mixed use Please late the HaaMnt form Property Use* Structures 341❑Clinic,clinic type infirmary 539 [:]Household goods,sales,repairs 342❑Doctor/dentist office 579 ❑Motor vehicle/boat sales/repair 31❑Church, place of worship 361❑Prison or jail, not juvenile 571 ❑Gas or service station i1❑Restaurant or cafeteria 419991-or 2-family dwelling 599 ❑Business office i2 ❑Bar/Tavern or nightclub 429❑Multi-family dwelling 615 [:]Electric generating plant .3 ❑Elementary school or kindergarten 439❑Rooming/boarding house 629 ❑Laboratory/science lab .5 ❑High school or junior high 449❑Commercial hotel or motel 700 ❑Manufacturing plant it ❑College, adult education 459❑Residential, board and care 819 ❑Livestock/poultry storage(barn) _1 ❑Care facility for the aged 464❑Dormitory/barracks 882 ❑Non-residential parking garage 11 ❑Hospital 519❑Food and beverage sales 891 ❑Warehouse outside 936❑Vacant lot 981 ❑Construction site !4 ❑Playground or park 938 ❑Graded/care for plot of land 984 [:] Industrial plant yard i5 [-]crops or orchard 946 ❑Lake, river, stream Lookup and enter a Property Use code only if i9 ❑Forest (timberland) 951 []Railroad right of way you have NOT checked a Property Use box: )7 ❑Outdoor storage area 960 ❑Other street Property Use 419 _9 ❑Dump or sanitary landfill 961 ❑Highway/divided highway 11 ❑Open land or field 962 ❑Residential street/driveway 11 or .2 family dwelling NFIRS-1 Revision 03 11 99 M Fire District 01920 01/15/2006 06-0000143 Person/Entity Involved Local Option Business name (if applicable) Area Code Phone Number �J IJackie IG I IDaurfman I L� check This Box if Mr.,Ms., Mrs. First Name MI Last Name Suffix same address as 1 inc idenskip the thret location . Then e I STARLIGHT DR 67 IJ I� duplicate address Number Prefix Street or Highway Street Type suffix lines. JABRAHANI, MUHAMMAD S & IMARSTONS MILLS Post Office Box Apt./Suite/Room .City IMMAA1 02648 -1 State Zip Code - ? More people involved? Check this box and attach Supplemental Forms (NFIRS-lS) as necessary. ? Owner Same as person involved? Then check this box and skip I I1508 - 2 7 4 - 9 5 8 5 The rest of this section. vocal Option Business name (if Applicable) Area Code Phone Number I IAmmad I Sheikh I L� Check this box if Mr.,Ms., Mrs. First Name Mi Last Name suffix same address as e incident location. '67 I " I STARLIGHT I- DR �J Then skip the three duplicate address Number Prefix Street or Highway Street Type Suffix lines.` IABRAHANI, MUHAMMAD S & I I "I IMARSTONS;MILLS Post Office Box - Apt./Suite/Room City IMAJ 102648 V l State Zip Code Remarks Local Option sller Name CELL PHONE CALLER TO PD IC : ELDRIDGE 3tS. . 1 nonroe 2006/01/15 03:57:21 - 304 AT EVENT MANNING IS 3 nonroe 2006/01/15 03:59:33 - 321 AT EVENT MANNING IS 1 nonroe 2006/01/15 04:12:22 - 324 AT EVENT MANNING IS 3 nonroe 2006/01/15 03:57:44 EPORTED BUILDING FIRE CELL CALLER TO PD nonroe 2006/01/15 03:58:03 D ON SCENE REPORT POT ON STOVE, NO FIRE, BUT SMOKE CONDITION nonroe ; 2006/01/15 03:58:46 04 ON LOC, SMOKE SHOWING nonroe ; 2006/01/15 04:01:17 DNFIRM POT ON STOVE, 304 COMMITTED VENTILATING nonroe ; 2006/01/15 04:02:23 21 REQ RESCUE FOR EVALUATION OF SMOKE INHALATION nonroe 2006/01/15 04:18:07 24 REPORTS-NO TRANSPORT, GATHERING INFO Authorization m�. 18260 I I ELDRIDGE, BYRON L. 11CAPT I IShift Comm I I 011 LL5J 1 2006 Officer in charge ID Signature Position or rank Assignment Month Day Year :cif® 18260 I I ELDRIDGE, BYRON L. I ICAPT I I Shift Comm I I 011 U 1 2006 Le Position or rank Assignment Month Day Year Officer Member making report ID Signature charge.. 01920 01/15/2006 06-0000143 MM DD YYYY 01920. U �J 15 2006 3� 06-0000143 000 complete Narrative FDID * State* Incident Date * Station Incident Number * Exposure arrative: 311er Name CELL PHONE CALLER TO PD IC : ELDRIDGE its. : 1 nonroe 2006/01/15 03:57:21 - 304 AT EVENT MANNING IS .3 nonroe ; 2006/01/15 03:59:33 - 321 AT EVENT MANNING IS 1 nonroe 2006/01/15 04:12:22 - 324 At EVENT MANNING IS 3 nonroe 2006/01/15 03:57:44 SPORTED BUILDING FIRE CELL CALLER TO PD nonroe 2006/01/15 03:58:03 D ON SCENE REPORT POT ON STOVE, NO FIRE, BUT SMOKE CONDITION nonroe ; 2006/01/15 03:58:46 J4 ON LOC, SMOKE SHOWING nonroe ; 2006/01/15 04:01:17 K DNFIRM POT ON STOVE, 304 COMMITTED VENTILATING nonroe 2006/01/15 04:02:23 21 REQ. RESCUE FOR EVALUATION OF SMOKE INHALATION nonroe ; 2006/01/15 04:18:07 24 REPORTS NO TRANSPORT, GATHERING INFO nonroe ; 2006/01/15 04:26:07 @ STA 3, 1 @ STA 1 RELEASED @ 0425 nonroe ; 2006/01/15 04:41:46 EQ FROM 321 TO CREATE OCCUPANCY FILE NOTING TEMPORAY TARGET HAZARD, BUILDING IS 3 PARTMENTS, LIMITED EGRESS, POSSIBLE BUILDING AND FIRE CODE VIOLATIONS. 321 WILL NOTIFY VSPECTOR MACNEELY asponded in 321 (1) with Sta. 1,2, 3 and Cotuit to a reported structure fire at 67 Starlight rive, MM. aroute, BPD reports food on stove, no extension, smoke condition in building. 304 continued asponse, 321,303,and 307 with traffic, all other units to hold. Don arrival of 304, 1 st wf, light smoke from side A. neck of building. confirms a cooking incident, no fire, moderate smoke condition in bldg. 04 ventilated w/ PPV. Two occupants c/o minor smoke inhalation, ambulance requested to scene D evaluate. con arrival of 324, 2 occupants of the first floor were checked for smoke inhalation, both efused transport. 303 and 307 ret. to qtrs. aeck of structure reveals 1 smoke detector outside bedroom has battery pulled back, not Drking, secnd detector in living rm, working. arther check of bldg. reveals it has been divided into three apartments, two on first floor" ad one in basement—This appears to have been done without any permit or inspection. asement has only one means of egress and 1 detector working, 2nd detector at bottom of ' taiis has a dead battery. Stove that food was left on was for this apartment and is on first Loor in what appears may have been a garage. Also found the second apartment on first floor ad no working detector. This apartment also appears not to be permitted. dvised, the .homeowner Mr. Ammad Sheikh, of findings and to put batteries in detector before D clears so all units have a working detector. Lso that no one should be sleeping in basement without a second means of egress. Mr. Sheikh tated he has batteries and will replace immediately and get second door opened for use. advised Mr. Sheikh that I would be sending Fire Prevention out to check smoke detectors for i Fire District 01920 01/15/2006 06-0000143 01920 U 1 1] 1 DD 151 1 2006 1 3 1 06-0000143 I 1 000 complete Narrative PDID * State* Incident Date * Station Incident Number * Exposure 3rrative: >mpliance. =ter venting, 304, 324 crews and myself picked up and ret. to qtrs. ie entire first floor and basement recieved minor smoke damage. No fire damage, other that >t of food, was noted. its building appears to have several health, building and fire violations. The appropriate jencies should be notified for response. )on return to station note to Fire Prevention and Chief regarding this call. ./15/20"06 07:54:32 beldridge rr t x;ro n;atrirt 01920 01/15/2006 06-0000143 , RECEIVED COMMONWEALTH OF MASSACHUSETTS MAR 10 2001 Z EXECUTIVE OFFICE OF ENVIRONMENTAL �BARNSTABLE H TH DEPT. DEPARTMENT OF ENVIRONMENTAL PR ON TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 67 Starlight Drive Marston Mills,MA Owner's Name: Mr.Sam Abrahanni Owner's Address: 67 Starlight Drive, Marston Mills,MA Date of Inspection: 2/23/01 Name of Inspector:(please print) Mr.Carmen E.Shay Company Name: Shay Environmental Services,Inc. Mailing Address: 34 Thatchers Lane East Falmouth,MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XX Passes Conditionally Passes �NOFA, Needs Further Evaluation by the Local Approving Authority Fails y �+ AY y Inspector's Signature: - Date: 2/23/01 0� RTI �P FS INS?E�' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea DEP)within.30 days of completing this inspection. If the system is a shared system or has a design flow of 10,00 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments 5' effective depth available at time of inspection in Leach pit#1 and leach pit#2. Evidence of liquid level being 12" higher in Leach Pit#L ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Starlight Drive Marston Mills,MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the_for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 Starlight Drive Marston Mills,MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if.the well water analysis, performed at a DEP certified laboratory, for coliform bacteria,and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: t , b .w Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 Starlieht Drive Marston Mills,MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system'component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped . Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 Starlight Drive Marston Mills,MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant, or Board of Health • 4 XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up XX Was the site inspected for signs of break out? XX _ Were all system components,excluding the SAS, located on site XX 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? . XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no XX _ Existing information. For example,a plan at the Board of Health. XX _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance ' is unacceptable)[310 CMR 15302(3)(b)] f Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 Starlight Drive Marston Mills.MA Owner: Mr. Sam Abrahanni Date of Inspection: 2/23/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): .5 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 550 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): 'No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None Available Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank,distribution box,soil absorption system - Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1992- per Owner& BOH Records Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Starlieht Drive Marston Mills,MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction: cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 10"to Riser Cover Material of construction: XX concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:= Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 5'deep x 5'wide by 10' Ion (1,500 yilons) Sludge depth: 4.0' Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness: ''/4 inch scum laver noted Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. 4" PVC Tee present at . inlet end. Outlet Tee present and in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of.outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ' Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): y 4 � Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Starlight Drive Marston Mills,MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(]ocate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Present (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 1/8" 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.): A minor amount of past solids carryover present which has resulted in minor scum build-up on bottom of one pipe for leach pit #1 D-box is structurally sound No evidence of leaks in or out of d-box. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): / Y 1/ Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Starlight Drive Marston Mills.MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. STARLIGHT DRIVE Swing Ties• A- Tank In— 16.5' B- Tank In—28.5' Exist House A-Tank Out—23' (5 Bedroom) B -Tank Out—33' B A- -D-Box-27' B—D-Box—37.5' A A- -Leach Pit#1 -38' B—Leach Pit#l —33' 0 A- -Leach Pit#2-35' Septic Tank B—Leach Pit#2—51' (1500 Gal.) Leach Pit#1 4 Leach Pit#2 Page 1 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Starlight Drive Marston Mills,MA Owner: Mr.Sam Abrahanni Date of Inspection: 2/23/01 SITE EXAM Slope Surface water - %:mile+/- Check cellar - Yes Shallow wells—None Estimated depth to ground water Over 15' feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Quadrangle of USGS Map CO?AMON T. TaI OF MASSAC --S TTS EXEcuTI�,°'E OFFICE OF ENT�r'IRO:V`'t?IEh'T_AI.AFFAIRS t DEPARTMENT OF ENVIRONMENTAL PROTECTION iAAP 00 PARCEL ; O N9 LOT TITLE OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 6 7 5-6r r t }'D�%d-4L fie_, 1MA FEB- 2 0 2004 Owner's Name: !'a Owner's Address: _(� 4 �JL TOWN OF BARNSTABLE ma t , m 04 ka HEALTH DEPT. Date of Inspection: J.I- y3 AO t Name of Inspector:Jplease,print)� el G Company Name: tAevvivLL Mailing Address: �. aNk Cya-6t11 Telephone Number — 08 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection_The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)- The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails y Inspector's Signature: Date: L A RlAk _r_7—7- The system inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments . ****This report only describes conditions at the time of inspection and under the conditions of use at that A time.This inspection does not address flow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/I5n0U0 page i t Page 2 of i 1 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,CERTIFICATION(continued) Property Address: l5 75�C�c i:T Owner. 1 Date of Inspection: Inspection Summary: Check A,B,CD or E I ALWAYS complete all of Section D A. System Passes: dl 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 will pass. Answer yes,no or not determined(Y,N,ND)in the for the following stet .If`not determined"please explain. The septic tank is metal and over 20 years old*or the sep' (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or ure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as' oved by.the Board of Health. 'A metal septic tank will pass inspection if it is s y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' ridable. ND explain: Observation of sewage bac or break out or 3ugh static water level in the distribution box due to broken or obstructed pipe(s)or due to a b settled or uneven won box.System will pass inspection if(with approval of Board of Health): broken pipes)aaesephtced obstructina isxemOved distnlirtian box is leveled or replaced ND explain: Th ystem required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will Pass, on if(with approval of the Board of Health)_ broken pipe(s)are replaced obstruction is removed ND explain: 2 i' pa—ge 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S�a� � i weer: T'a-� , D Date of Inspection: � b'�( 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 a system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CIVIR 2- 03(l)(b)that the system is not functioning in a manner which will protect public health,safety an a 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 it marsh 2. System will fait unless the Board of Health(and Public Wat Supplier,if any)determines that the system is functioning in a manner that protects the public h h,safety and environment: _ The system has aseptic tank and soil absorptions em(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water su ly. The system has a septic tank and SAS and t SAS is within a Zone I of a public water supply. The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method d to determine distance **This system passes if the well ter analysis,performed at a DEP certified laboratory,for colifo.rn bacteria and volatile organic pounds indicates that the well is free from pollution from that facility and the presence of ammonia n' ogen and nitrate nitrogen is equal to or less than 5 ppm;provided that no other failure criteria are true .A copy of the analysis must be attached to this form. 3. Other: 3 4� Page 4 of 11 OFFICIAL INSPECTION FORK—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DAL SYSTEM INSPECTION FORM PART.A CERTMCATNJN(continued) Property Address: Owner- Date of Inspection: D. System Failure Criteria applicable to all systems- you must indicate`yes"or"no"to each of the following for all inspections: Yes No -X 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 y 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 tim/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped �( Any portion of the SAS,cesspool or privy is below high grourid water elevation. J Any portion of cesspool or privy is within 100 feet of a surface water supply or tnbutary 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-I Thb system passes if the well water analysis, performed at a DEP certified laboratory,for cofform bacteria and volatile organic.compoiaNdS indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal-to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) (YeslNo)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 fa a e. E. Large Systems: To be considered a large system the system must serves facility Will I design flaw of 10,000 gpd to 15,0t1i1 gpd, t = You must indicate either"yes"or"no"to each of the fo (The following criteria apply to large systems in ad to the criteria above) yes no _ — the system is within 400 feet a surface drinking water supply — the system is within feet of a tributary to a surface drinking water supply — — the system is I d in a nitrogen sensitive area(Interim wellhead Protection Area—IWPA)or a mapped Zone fl of ublic water supply well If you have ans red"yes"to any question in Section E the system is considered a significant threat,or answered `yes"-n Secti D above the large system has failed-The owner or operator of any large system considered a significant under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304.Th system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address* 7 Owner: bra O+� Date of Inspection: %\ X;1 p` Check if the following have been done.You must indicate es"or"no"as to each of the following' Yes No jC — 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 y — Has the system received normal flows in the previous two week period? A 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? A — Were the septic tank manholes uncovered,opened,and the h tenor of the tank inspected for the condition fhe 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: Ys n© Existing information.For example,a plan at the Board of Health X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM IN-FORMATION Property Address: 6-7 Owner: Date of Inspection: R�' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):__e Number of bedrooms(actual): S m DESIGN flow based on 310 CMR 15-203(for example: 110 gpd x�of bedrooms):L� Number of current residents: 3 Does residence have a garbage grinder(yes or no):YCS Is laundry on a separate sewage system(yes or no):— (if_Yes separate inspection required) Laundry system inspected(yes or no):� Seasonal use:(yes or no): 00 1 gy 4 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):00 Last date of occupancy: Etlt� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15. 5 203):_ gpd Basis of design flow(seats/persons/sgft etc: " Grease trap present(yes or no):— Industrial waste holding tank pre es or no): Non-sanitary waste discha ged to a Title 5 system(yes or no):_ Water meter readings,if avail e: Last date of occupancytuse- OTHER(describe): GENERAL INFORMATION Pumping Records G�,dhi( Source of information:Was system pumped aspart spection(yes or no): D If yes,volume pumped:____--gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM JL 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/Aiternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank `Attach a copy of the DEP approval Other(describe): Approximate age of all components date in W f known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORI PART C SYSTEM IN'FORIVIATION(continued) Property Address: &I Owner' CW t Date of Inspection: BUILDING SEWER(locate on site plan) . It Depth below grade: c3 I Materials of construction:_cast iron 440 PVC—other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) k M Depth below grade: _ Material of construction:,g_concrete metal - fiberglass,polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) t Dimensions: !SO0 fir-a Sludge depth: —1 " �t+ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_Sr t r Distance from top of scum to top of outlet tee or baffle:_ 10 Distance from bottom of scum to bottom of outlet tee orbaffle: l N How were dimensions determined- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity-,liquid levels as relate-4 to outlet invert,evidence of leakage,etc. e ez uk -k \l h C'C JPAt GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete metal fi a lass-_polyethylene other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of o et tee or baffle: Distance from bottom of scum to ttom of outlet tee or baffle: Date of last pumping: Comments(on pumping re endations,in and outlet tee or baffle condition structural integrity,liquid levels ' as related to outlet inve evidence of leakage,etc): 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: fs7 gr��Skt m��'y< -- ;W" Owner- aA� Date of Inspection: 1 OC TIGHT or HOLDING TANK: (tank must pumped at time of inspection)(loc ate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: day Alarm present(yes or no): Alarm level: in working order(yes or no): Date of last pumping: Comments(conditio of alarm and float switches,etc.): resent must be ocate on site plan) (if � DISTRIBUTION BOX: X ( p � Depth of liquid level above outlet invert: Q J?M Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage mto or out of box,etc-): PUMP CHAMBER i(locate on site Pumps in working order(yes or Alarms in working order(ye r no): Comments(note conditio ofpump chamber,condition of pumps and appurtenances,etc-): 8 Page 9 of I I OFFICIAL INSPECTION FORM—1tiOT FOR VOLUNTARY ASSESSNIEINNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIVi PART C SYSTEM INFORMATION(continued) Property Address: 1 G� Owner: un�. Date of Inspection: L SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number leaching chambers,number leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding damp soil,condition of vegetation. etc.): 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 groundw er inflow(yes or no): Comments(note c dition 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 conditi of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 a Pa_e 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 PART C SYSTEM INFORMATION(continued) Property Address: 7 S tom"l t wA �)C%J" R-5 Owner. K Date of Inspection:_� SKETCH OF SEWAGE DISPOSAL SYSTEM provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks_Locate all wells within 100 feet Locate where public water supply enters the building_ &AIr �b 33 81 38 S1' a ' . Page l l of I l OFFICIAL INSPECTION_FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IiISPECTIONtiT FORM PART C SYSTEM INFORMATION(continued) Property Address 0 t Dr c �S Owner- Date of Inspection: 17 1310,4 SITE EX&AM Slope �J Surface water Check cellar Shallow wells 0 Estimated depth to ground water�Q Meet Please indicate(check)all methods used to determine the high around water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water Elevation: Ll 5 65G.�a, �►l-,n� c, Q�edGv`t .. I A o� of ao !1 No....! e ......... 1 � 'r F�s..a`- ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......TG EvkJ......... OF............... , 9J-19h�s/' �L pplication.for 15toposal 10orksTonstrurtilin Vrrmft Application is hereby made for a'Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal System at: 2,0s sT�.�Lr �� -t�hi�� ............................................................. --------- ------....•--•��lf, oration-Address G �f or - = . � =--------/- ----------------- --------.....------------......------------..----------------------------- w i Ow r Address ........ Q Installer Address VType of Building Size Lot..---- ___Sq. feet Dwelling—No. of Bedrooms_.... ................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------••-------•----•--------------••--••-----------•---•----•-----•••------•--•••---•-•...----•---•--•-•-------•••-•---•-•_._.. w Design Flow............... .0.................gallons per person per day. Total daily flow----------3_QA�- ..3..QA�-­­--------------9 allons. WSeptic Tank—Liquid capacity__004gallons Length................ Width---------------- Diameter---------------- Depth__-___.__-___-. x Disposal Trench—No.. .................. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.../a11f _.. Diameter-------------------- Depth below inlet____________________ Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date------------------------------------ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-----------___--____.--. PLq Test Pit No. 2................minutes per inch Depth of Test Pit__----__-_______-._- Depth to ground water_-____________--____-_-. 9 ------------------------------------------------------------ -------------------------------------------------------------------------------------------­­ 0 Description of Soil-------------------------------------------------------------------- -------------------------------------------------------------------------------------------- c, --•••-•�h.�vf-L----- --JO`-�7----•------------------------------------------------------------------------------ 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beT issued by the board of e th. Signed----x ----••-- j��------- - y- /y-73 Date Application Approved BY - -------------------------------------•---------•--•------- ------ ..........Y:-M�'�--7�--------- Date Application Disapproved f o the f ollowi reasons:.-•----------------------------------------•-----------------------------------------------Da.t e.............. ---------------------------------•--------------•----------------------------•----------....-------------------------------------- Date. Permit No. -...__. Issued. - --7 ate A_ No.. "3 Fimiic.., .. zJ.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH t,,A.,' : Aliptiratiun for 11i,spngttf Works Tonstrnrtion Permit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: { ............................................................. --------•------------------------ ---------•••--------•---•••-•-.... ---•--•----•---------•_. _,Location,-Addr ss or Lot No 4 .................. .....�.-.. / .... .............. .................................... ......... ..............�._._...__.._.............. _ Owner Address 77 �•� - Installer Address •r; d Type of Building Size Lot.... ......:.. ! ..._Sq. feet V Dwelling—No., of Bedrooms.......3.....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ....... No. of persons............................`Showers a YP g ---------.•.--------• P _ --(•--->..— Cafeteria ( ) d Other fixtures ................................. •--------------- •------------------------------------------------------ ------ W Design Flow...............:`i_l/'.x..................gallons per person per day. Total daily flow---------. ..ewZ2.....................gallons. WSeptic Tank—Liquid capacity.P:tXf gallons Length................ Width................. Diameter---------------- Depth_-.-_____.-_-.-. x Disposal Trench—No........................ Width.................... Total Length.................... Total leaching area______-__-_--_--_-sq. ft. Seepage Pit No._.Z_r.�' .d... __ Diameter.................... Depth below inlet.................... Total leaching area.....,------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1..._............minutes per inch Depth of Test Pit.................... Depth to ground water-_.-___-_-___-__-__.---. GL, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 94 -••••-••-••-----•--------------•-•------•••-••--••-••••---•---•--=••---•••-•--------•-•--------••-----••---••-•--•---••------••-•-•••--•-----••-•--••••---- ----•••. ... ------------•----------�/ Description of Soil `} s c_ We'tW 4 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 Article XI of the State Sanitary Code. _-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of..h lth. fi pr Signed ' t ------------ ,f § Date /� { - Application Approved BY - b tl ~ ......... Date Application Disapproved for the f ollowin reasons:...•••-------•--•--•-•--••-----••-•••••-••-•-••---------------••-•---•---------••-•••••• ••----•-•---------. --------------------------•-------------------------------------•-----------------------------------------------••--------------------------------------------------------------=----------------- Date PermitNo.......... -- ----. -----------------•--•--------. Issued. ' ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH b4,,,�' .1.......OF......... :.. t" 3- ......................................... .................. Trrtif iratr of Tomptiatta THIS IS TO CERTIFY, That, the Individual Sewage Disposal System constructed (fir Repaired ( ) by ? E x.•f ... . 4 Installer at--------- ........... I --------==" '--'' . t C ..L = w "Y4fi........................ has been installed in accordance with the provisions of Article X] of The State Sanitary Code as des ibed in the application for Disposal Works Construction Permit No------- . ................... dated------------ - ..£.a':'......�u......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL UNCT N SATISFACTORY. DATE-- •. ................................... Inspector- .- 4 ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7..,� c &' i..........OF..... . ...t..E ..A s Z.s�✓ ........................ No........ ............ FEE .................... Ditipwial luorkii Tomitrnrtiuit Permit Permission is hereby granted....'_ �`1 tr f� : "`• � ' � " mot to Constructs( ems) o`er° Zepatr ( ) an Individual Sewage Disposal ystem atNo. A'.. -•----- ----- ---- --- .................... ° Street i as shown on the application for Disposal Works Construction. it No l;' ?. _ ated___.____` __"_ _✓::.'77Z._.. 00 ....................- Board of ea121 ; DATE ... FORM 12 5 HOBBS & WARREN. I-NC.. PUBLISHERS - � t.