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0098 STARLIGHT DRIVE - Health
98 S T ARUGHT DR! /E; MARSTONS "lCLS - A = 100 049 I �i TOWN OF BARNSTABLE e LOCATION ✓aF SEWAGE # 2000- 270 `V .,LAGE l Me_1TorlS 112A ASSESSOR'S MAP &LOT !D1:9- 9f INSTALLER'S NAME&PHONE NO. 529 -y2o q736Z SEPTIC TANK CAPACITY AVO 6*14/ / LEACHING FACILITY: (type) (size). .2SX/3 NO.OF BEDROOMS BUILDER OR OWNER coati"e i?9�src CIOs>rl��� PERMTTDATE: 7-66 k COMPLIANCE'DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fac' ry) Feet Furnished by zal BAIA a a No. t q Fee /UO THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplicatton for Migozal �&pgtem Con.5tructton Verrntt Application for a Permit to Construct( ) Repair( ) Upgrade,`�j Abandon( ) ❑ Complete System 9 Individual Components Location Address or Lot No. Owner's Name,Address,and Tel No. 98 5TAkL)6dT ZRivC_ ✓pANA/� /rl9C CaNn/C-LL Assessor's Map/Parcel /r) 914 PQkC. -9 %9 ww,.j awj- jA - 1 4lur ml1-Ls Installer's Name,Addr,e36, �ss,and Tel.No.5,,8- yZ e- �'�� Designer's Name,Add less and Tel.No. ` " ��3-1 9� �os,c�dr dt U.4P 'dS 4 Z 6 YL, � i9.ss4TC/,#7C� Type of Building: Dwelling No.of Bedrooms e3. Lot Size 2,0 �B sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 2 Design Flow(min.required) 33 b gpd Design flow provided gpd Plan Date ao - Z—D 6 Number of sheets t' Revision Date Title S,15W(46-'C SY'.S), aR66"b& )r-OX— -,/MWAA� ^4 c C071.rA15: i'Z. Size of Septic Tank >. 04FO G, OlS7P/l14. Type of S.A.S. C* mgiJ -19 Description of Soil /dk 3Z°' 44-41)7 s S k G Z" - /32 ce4s&- ay 4D Io Nature of Repairs or Alterations(Answer wh applicable) _� - r O6.1 /a,TX y-,� ,n-- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H,,,ee, alth./h. Signed .i( All, Date Application Approved by A A I �. Date 6e Application Disapproved by: ,Date , for the-following reasons Permit No. 100 6 T 70 Date Issued ,. • ... `g - :v"nV`_+'t �,:'-:.e Yam. ,.+er' J. ��r� .. /00 No. l/w , 7 �.M� THE COMMONWEALTH OF MASSACHUSETTS Entered,Rrcomputer: V PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliration for Digozal 9Pp9tem Con5truction Permit Application for a Permit to Construct( p Repair( ) Upgrade( Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. C- 9$ STAkL i 61)T -bRI Vc- .1a 4AIA)E �19c C�WC- L Assessor'sMap/Parcel /n fj,4 /,60 P,IRC T9 98 ST�Q,C4,Gy�- .�� _ /y44,r7, 14/L- LS Instal er's Name,Add res.,and Tel.No. Desi ner's Name,Addr ss and Tel.No. �sAti Oe �arroS .J�.d oYG, �sS6G iy?F� Type of Building: Dwelling No.of Bedrooms Lot Size 2 O1 D D O sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 Q. ' gpd Design flow provided gpd Plan Date G Number of sheets / Revision Date Title SySr, VA(g,"bc )Cy,#_ :.;,-) A/A/F M,4c GAIAI&GL Size of Septic Tank f 04 D &, all Z /NG Type of S.A.S. CW/9In&_-4 LC/» Description of Soil Q 14'/ 404f'yJ 15 le 3 / �N, . 3Z"' /1i9�YI .5.4/1.l , S IRL G Nature of Repairs or Alterations(Answer whe applicable) -1 Date last inspected: Agreement: V The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme,'ntal Eode and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. t. Signed V & Date ApplicationApproved`b Date D P PY 7/ G Application Disapproved by: Date for the following reasons Permit No. )dab — a 76) Date Issued r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Eompriance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded I Abandoned( )by ✓3r.��xl /,;�e at f n 0s .W%Ze* jr .�?s�tff has been constructed in accordance with the provisions of Title?5 and the for Disposal System Construction Permit No. s2n�� — 2 7 0 dated 1.` 1 6 . Installer v�GtS+ f � ..G It,,Ns" � Designer ,e A;4eZe 01:rae /�k?'res #bedrooms Approve<ddes'gn,-Q,0� , gpd The issuance of this permit h 1 not e corfstrued as a guarantee that the syste funct�'naas dYDate Inspectos r _ __ No. 0� - 270 -------------------pF-- "—Fee Ajd^----- - THE COMMONWEALTH OF M.A S$AC:IUSE.TTS t� d��a PUBLIC HEALTH DIVISION—BARNSTAB`LE, MASSACHUSETTS Bigont �&pgtem Con!5tructiou Permit Permission is hereby granted to Construct ( ) Rep/air ( v) Upgrade ( —Abandon ( ) System located at 540ell, ,+' 49e and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Con traction m'_st be complMed within three years of the date of this p tmit. Date (� ��U 1pprove&by vilO'�,6 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM 40>149� ,hereby certify that the engineered plan signed by me dated G Z d ,concerning the property located at 9%? meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances.requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 7 2 ' B) G.W.Elevation +adjustment for high G.W. = 3s 6�04 cowrr avv_ w!*A_ DIFFERENCE BETWEEN A and B 3 SIGNED : ' DATE: t 't NOTICE Based upon the above information, a repair permit will be issued for ' bedrooms = > maximum. No additional bedrooms are authorized in the future without engineered septic system plans. 3 _ a y r q:\Septic\percexemp.doc �' 00 - D7-9 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' a 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page.e. Cityrrown State Zip Code Date of Inspection Ike Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out fortes 54- on the computer, use only the tab 1. Inspector: key to move your cursor-do not A.Riker use the return Name of Inspector key. R.L.C. � Company Name PO Box 726 Company Address South Yarmouth MA 02664 Cityrrown State Zip Code 508-776-6460 S14590 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 01/16/2016 Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal^System-Page 1 off 17 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection there were no failures observed . Conditions are only what was observed on day inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3A 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. City/Town state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Property was said to be a three bedroom residential dwelling . Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2015=74 GPD g ( y g (gp ))' 2014=110 GPD Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: unknown Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Bi annual maintence pumping recommended Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 .f • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Tank installed in 1975 and new leach chambers installed in 06/09/2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: town water enters front of dwelling feet Comments(on condition of joints, venting, evidence of leakage, etc.): Interior ejection pump for basement bathroom not inspected for operation. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 1000 gallon precast concrete tank with concrete baffle on inlet and PVC tee y on outlet. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5x5x8'6" 6" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 n/a Scum thickness 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 15" 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.): no failures observed at time of inspection. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 .�C\ Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-.3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t , a Commonwealth of Massachusetts RUMP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 98 Starlight Drive Property Address J. Shea Owner owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert equal to both outlets with leviers in place 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.): No indication of failure observed Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts t M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A -/ =ao2 a a = a3� - l - sL a = SS' 3 ; t�s• o 0 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owners Name information is required for every Marstons Mills MA 02648 01/16/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >11 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked,date of design plan reviewed: 06/02/2006Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Test Hole on file performed 06/02/2006 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole on file with engineered plans with certification letter reviewed.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 98 Starlight Drive Property Address J. Shea Owner Owner's Name information is required for every Marstons Mills MA 02648 01/16/2016 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 0 as COMMONWEALTH OF MASSACHUSETTS � EXECUTIVE OFFICE OF ENVIRONMENTAL FAI7i/ o :""E7O , DEPARTMENT OF ENVIRONMENTAL PRO EC lunTOti TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner's Name: FRANCIS MADIGAN Owner's Address: P.O. BOX 20670,WORCESTER,MA.01602 Date of Inspection: 10/19/01 Name of Inspector:(please print).. . , JO1JN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O..BOX 2119 TEATICKET,MA.02536 Telephone Number:508-564-6813 FAX 508-564-7270 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: F . i X Passes _ Conditionally Passes _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: ' Date: 10/19/01 The system inspector shall submit 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 SYSTEM PASSES TITLE V RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM USEFULL LIFE. ""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. TWO 5 Inc......tinn Gnrrn y ' Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM USEFULL LIFE. 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. n/a 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:n/a n/a 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:n/a n/a 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:n/a Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 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 n/a "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: n/a A of f Page 4 of 11 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow _ X Required pumping more than 4 times in the last year NOLdue to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (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 X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" In Section D above the large system has fhlled,The owner or operator Of ally large system considered tl slgltlfleant 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. A Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank,manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance` of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] S Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents:0 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): n/a Sump pump(yes or no):NO Last date of occupancy:6/20/01 COMMERCIAL/INDUSTRIAL Type of establishment:n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.):n/a Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings,if available: n/a Last date of occupancy/use:n/a OTHER(describe):n/a GENERAL INFORMATION Pumping Records Source of information:n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped:n/agallons--How was quantity pumped determined?n/a Reason for pumping:n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: APPROX 30 YEARS Were sewage odors detected when arriving at the site(yes or no):NO r. Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 ? BUILDING SEWER(locate on site plan) r Depth below grade:22" r Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC Distance from private water supply well or suction line: n/at Comments(on condition of joints,venting,evidence of leakage,etc.): t _ TOWN WATER + SEPTIC TANK:X(locate on site plan) Depth below grade: 16" t , Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age:n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: 1000G L 9'H 6'W 51311 H20" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" l . Scum thickness:4" Distance from top of scum to top of outlet tee or baffle:6" +- Distance from bottom of scum to bottom of outlet tee or baffle: 14" " 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.): , THE MAIN SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO.YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.RECOMMEND SEPTIC BE PUMPED NOW GREASE TRAP:_(locate on site plan) Depth below grade:n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain):n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or battle: n/a Distance from bottom of scum to bottom of outlet tee or baffle:n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or battle condition,structural integrity, liquid levels as related j to outlet invert,evidence of leakage,etc.): n/a 7 Page t0 of 11 ti OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: 98 STARLIGH T DRIVE MARSTONS MI LLS,MA 02648 P Y Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 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. bar d SS in Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 BUILDING SEWER(locate on site plan) Depth below grade:22" Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK:X(locate on site plan) Depth below grade: 16" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a . If tank is metal list age:n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 9'H 6'W 5'3"H20" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness:4" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" 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.): THE MAIN SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.RECOMMEND SEPTIC BE PUMPED NOW GREASE TRAP:_(locate on site plan) Depth below grade:n/a Material of construction:_concrete_metal_fiberglass jolyethylene_other(explain):n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 w OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity:n/a gallons Design Flow:n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000G 6'W X6'HD leaching pits, number: 1 n/a leaching chambers, number: nla n/a leaching galleries, number: n/a n/a leaching trenches, number, length: nla n/a leaching fields, number: n/a n/a overflow cesspool, number: nla n/a innovative/alternative system Type/name of technology: nla Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.PIT IS IN 2 FEET OF STONE.SIGNS INDICATE THAT I FOOT OF LEACHING REMAINS.PIT WAS EMPTY AT TIME OF INSPECTION.BOTTOM AT NINE FEET. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer:n/a Depth of scum layer:n/a Dimensions of cesspool:n/a Materials of construction:n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions:n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a " 4 Page l0 of 11 L OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 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. 1 e- ---] '1 0 B Ll 4A Af �3 6C in I' fj Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 STARLIGHT DRIVE MARSTONS MILLS,MA 02648 Owner: FRANCIS MADIGAN Date of Inspection: 10/19/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed:n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain:n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: NO GROUND WATER FOUND BY AUGER AT 12+FEET. ,a� TOWN OF BARNSTABLE �SS�� I:OCATIOR SEWAGE # III s NCvk VII.,LAGE ASSESSOR'S-MAP &LOT-(jq� (P� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r -IA ®ec� ® A. 460 AC -:a`f sit of, SS � 7� TOWN OF BARNSTABLE LC,CATION �� �-r SEWAGE # �i&LAGE �{o w oASSESSOR'S /MAP & LOT ZOO. 0 TaT[T A i � �[/� �/i l/ /t i r /�:]J SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (si )� NO.OF BEDROOMS0EN ✓ 7 OWNER PERMITDATE: CE DATE: Separation Distance Between the: Maximum Adjusted Groundwat Ta etc the Bottom of Leaching Facility Feet Private Water Supply Well anbdlzaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Town of Barnstable Regulatory Services • Thomas F. Geiler,Director '► )AENSTMM « "ASS. 1639. Public Health Division on �ATfD MAC A �s Thomas McKean,Director s 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 15, 2006 Ms Joanne MacConnell P O Box 340 West Ossipee,NH 03890 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 98 Starlight Drive,Marstons Mills,MA,was last inspected on April 15th,2006 by,Patrick M. O'Connell,certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Leaching pit has no effective leaching. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean,R.S.", C.H.O. Agent of the Board`of Health ' 8 COMMONWEALTH OF MASSACHUSETTS kipEXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 98 Starlight Drive Uy/� Marstons Mills MA 02648 Owner's Name: Joanne MacConnell Owner's Address: PO Box 340 West Ossipee NH 03890 April 15 Date of Inspection: ,2006 Job# 06-I l l Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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 Doittt/// approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ������ OF Passes ';yG _ Conditionally Passes = P TNI _ Needs Further Evaluation b the Local Approving Authority = 'm+= _X_ Fails r ELF Date: 4/15/06Inspector's Signature- S I NSFP�E,`'����Qv�`��` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Outlet baffle in tank is missing and leaching pit has high stain lines above inlet invert, pit has no effective leaching. ****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 some or different conditions of use. r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 f 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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 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: i✓ Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 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 _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than—day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now 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 Iodated in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No _X Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? 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? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been deten-nined based on: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell , Date of Inspection: April 15,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents:0 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)): Two years total: 179,000 gal.=245 gpd. Sump pump(yes or no): No Last date of occupancy: More than 2 weeks prior to inspection. COMMERCIAL/IN DUSTRI A L Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _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: 1970's Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 BUILDING SEWER:XX (locate on site plan) Depth below grade: 2' Materials of construction:_cast iron _X_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: 2' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.511ong x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):. Outlet baffle missine liquid level at bottom of outlet invert. GREASE TRAP: No (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.): Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal_fiberglass_polyethylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number:One 6x6 pit _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.): Leaching oit has a high stain line over too holes in ait leaving no effective leaching. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 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 a ;:4 Water Service 14 iv i . 23 55 2 76 Page 1 I of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 98 Starlight Drive,Marstons Mills Owner: Joanne MacConnell Date of Inspection: April 15,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: 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 elevation: A perc test will be performed prior to inspection to determine groundwater elevation. T wn of Barnstable to 'Regulatory Services Thomas F.Geiler,Director � 1e►R1Y51'A,$F:E, + a Public Health D vis un id Thomas McKean,Director 200 Main Street;Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: U 2tX� Designer: �(0{f tJ d L.,e_ A,950L Installer: J6 Address: . Address: —&P 4ovotpy5 was issued a permit to install a (date) (installer) septic system at DKI V-r:::; based on a design drawn by (address) -:1104 4 DN ASb6, dated le —7-06 (d signer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved-changes such as lateral relocation of the distribution box and/or septic tank. _ I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any verti9al relocation of„ny component of the septic system)but in accordance with State&Loc ons. Plan revision or certified as-built by designer to follow. FA`�H o MASS° taller's Signature) .p o t GIST0, f SANITAO'a p6 o (Designer's Sign e) (Affix Designer's Stamp He PLEASE RETURN TO BARNST LE PUBLIC HEALTH DIVISION. CERTIFICATE OF COlYIP1..IANCE WILL NOT BE ISSUED ITNTIL BOTH -THIS FORM[ AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH`DIVISION. THANK YOU. Q:Healfh/Septic/Designer Certification Form THE COMMONWEALTH OF MASSACHUSETTS BOARD.X Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Yst Location-AZd r or Lot No Owner Address Installer Address .20 �� C4 Septic Tank—Liquid capacity '---------------------------------------------------------------'-- 8grecoeot: � The undersigned agrees to install the afore6escri6ed Individual Sewage Disposal System in accordance with the provisions of Article XI of He State Sanitary Cod — The undersigned further agrees not to place the system in SX1 - operation until Certificate ofC �zSig issued �����'�� �����'�����- _S u*" _ Application Approved DT—..� ��u����� -----' ~ u*, Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------'-----^-- ,.,-~~^ � Permit No......................................................... Issued........................................................ u,m No........................ Fmic... ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD WEALTH H I*- -------.OF......... .................... ApVhraflon -for Uhipoiial Works Totu4rurfiott Vrruift Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: � 9 . .&...........�ZAEL T__z—A lez. ................ ............ ......................................................... Location-A or Lot y Id/ o L. No. N."I 7-, ? .............. .. ...................... ------ ...... ... ..................................................... .... Owner Address .................................................................................................. .................................................................................................. Installer Address 2o npt.) Type of Building Size Lot-._�------------------Sq. feet Dwelling—No. of Bedrooms--------3_.............................Expansion Attic Garbage Grinder Other—Type of Building ---------------------------- No. of persons..-_----------_--___-____--- Showers Cafeteria Other fixtures ----------------------------------- ------------------- --_----------------- ----------------- 3 ---------gallons.--------------------------------------------------------------- Design Flow----------5-0 a ----- -------------------------gallons per person per day. Total daily flow------9 Septic Tank—Liquid capacity_,"_i'..gallons Length________________ Width..-_-..-_.._._.- Diameter_._.._......_... Depth----------_--- Disposal Trench—No_ -------------------- WidVi-------------------- Total Length Total leaching -area..-.----------------sq. f t. Seepage Pit No.--_-!_____________ Diameter_,//_49'6"D----- Depth below inlet-9-n Total leaching area.............. s(l. ft. I Dosing tank 7 S Other Distribution box ( ) Percolation Test Results Performed by......... ---------------------------------------------------------------- Date--------------------------------------- a Test Pit No. I................minutes per inch Depth of Test Pit-..--_-______-____-- Depth to ground water...---_-_--_-----.-.__.. (i Test Pit No. 2----------------minutesper inch Depth of Test Pit.............._..__. Depth to ground water--._.__--_-__--.-______- _._....--- --------------------- ......................?,../ ....... 0 _�------- ----------------------------------------------- Description of Soil-----Z�i.....0...... ---ttk_v I I - �Z---------- --------- ----------- 7 ---------------- - - - .... --- ----- ------------------------------------------------- Y7------....1) , V -, , ___,- ;2 '.2 td&57 U --------------------------- ------ ----7... ------------�;;_: ---------------------------------------- �Ve---L;__44 ------------------------------------------------------------------------------------------------------------------- Nature of Repairs or Alterations—Answer when applicable.-.------------ ------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned'further agrees not to place the system in operation until a Certificate of Compliance has beep issued by the oard of: hn Itl . Slgne , k ------- ---- ------- --------------- ------------------------- ----------------- r'!LT— Date .— Application Approved By----- T_ ------Zi----------- ....... ..................... Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ................................................ ....................................................................................................................................................... Date PermitNo......................................................... Issued---------------------- ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........V. Z,�.. .........OF......... C4_t_�................................... QVIrdifirate of Tomptiaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (/,/) or Repaired by_=------------------------------------------------------------ i 4�i ................................. -�i, -Z------------------------------------ e --ii e ---------itis, Z, .... ....... I . . ........................... ......... at------ - -- ------ "Xt� the provisions_ cfe 0 has been installed in accordance 1 e isions of 'Arti I XI f The State Sanitary Code as described in the r, , , application for Disposal Works Construction Permit No._!-I---.......2.....----�y-------------- dated'_F.-..,0..-..7.K.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------- Inspector------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........:; ......... 0 F...... .22 -- .............................. ./. . 1 t-4,....................I... No......................... FEE... ............. Permissionis hereby granted- ---------------------------------------------•-------------------------•----•-•; ----------------------------------------------- to Constrt)ct ( '-�7,or/Rep ir. a Individual Sewa5erisposaLSyste m ............11.22.6-1,11-- -------------/---------- -------------------------------------------------- _Z /�p Z: at No----- _,4,Y_Z Street as shown on the ap plication for Disposal Works Construction P'pr9it No I.-------------/)----- Dated--- ----------- ................................... 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