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0011 STAYSAIL CIRCLE - Health
11-Stay ail Circle Marstons Mills F A = 058 016002 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '9M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at.the end of the form. i A. General Information 1. Inspector: I �V� Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-27-14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and-copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. V t5ins•3113 , Title 5 Official Inspection VF. urlfaceewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 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: System is in good working order with no sign of failure. B) System Conditionally Passes: i ❑ 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. I *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. j ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C Further Evaluation is Required b the Board of Health: 1 q y ❑ Conditions exist which require further evaluation by the Board of.Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4'9M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °7M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is Marstons Mills MA 02648 6-27-14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well lf.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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 IIL Commonwealth of Massachusetts W Title 5 Official Inspection Form �m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °7M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 6-2014 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Staysail Cir 'M Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner pumped 6-2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 12 Sludge depth: t5ins•3113 Pd Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 l Commonwealth of Massachusetts m W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments condition of alarm and float switches etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. 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•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 III Commonwealth of Massachusetts = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition and holding 2" of water with no visible stain lines. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy locate on site plan): Y ( P ) Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts T W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is Marstons Mills MA 02648 6-27-14 required for every ' 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 C AD 7 ° . a - - / 4F , � 7 d t5ins-3/13 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Staysail Cir Property Address Gareth Markwell Owner Owner's Name information is required for every Marstons Mills MA 02648 6-27-14 page_ City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this addreLs and that the information reported below is true, accurate and complete as of the time of the inskre tion. The insption was performed based on my training and experience in the proper function and main enance of on sjte sewage disposal systems. I am a DEP approved system inspector pursuant to S tion 1CA340 of Title 5 (310 CMR 15.000).The system: rn ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev ation by the Local Approving Authority 10-15-08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system.owner .14 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. r1 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts W Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D' A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection , B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: El Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 11 Staysail Cir Property Address American Home Mortgage i Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in.the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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`fifes"or"no"to each of the following, in addition to the questions in Section D. y 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every 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)] t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 8-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No r Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: - gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments- 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 30" - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ---------------------------------------------*----------------------------------------------------------------------------- `Dimensions: 1000 Gal "Sludge depth: 10" f -Distance from top of sludge to bottom of outlet tee or baffle 22" ` Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6' Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5inspofficial document-03/08.' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town- State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles in place. l 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.): 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):, t5insp official document-03/08 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form ? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps'and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition with no visible stain lines. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons'Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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 official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts AU�., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. CI st - 3o'r` t5insp official document-03/08 'title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Staysail Cir Property Address American Home Mortgage Owner Owner's Name information is required for Marstons Mills MA 02532 10-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: . 12 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: Original design plans show no groundwater at 12'. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 T Town of Barnstable E.r Regulatory Services Thomas F. Geiler,Director iAR1Y AM. q Public Health Division €639. `far FFo. a Thomas McKean,Director 200 Main.Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 509-790-6304 Installer &Designer Certification Form Date: UU S 6 Designer: t - ry !�f✓l?, � en l e Installer: Address: . t' , ��C �r �l` Address: �J � � ✓may oix?? On ® 6' J T was issued a permit to install a (date) (installer) septic system at 5 c:.. based on a design drawn by (address) e-x-- dated —�� (designer) k -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 he distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e, greater than 1.0' lateral relocation of the SAS or any vertical re ation of any component of the,septic system)but in accordance with State&Loc Plan revi J, or certified as-built by designer to follow. ° . DARR N , o M. MEq10RE y 140 ., (Installer's Signature) ASTER SgNITARI P� (Designer's Signature) (Affix Designer's.Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CONd WACE WILL NOT BE ISSUED UNTIL BOTH -THIS FORM AND AS-CARD ARE RECEN ED BY THE B.A RNSTABLE PUBLIC HEALTH DIi�ISIOl� THANK YOU. Q:HealtIVSeptic/Designer Certification Form 2"1 z,-1 COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RE ;EIVED Sre MUD INSPECTION FEB 0 s 2005 i TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ] Property Address: 11 Staysail Circle 'AR;E=17. ,. �� 2-' Marstons Mills MA 02648 Owner's Name: Michelle Wright Owner's Address: Same Date of Inspection: January 13,2005 Job#05-12 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``, 1�tUl� ' approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system***�� N OF Af S/, Passes sYcl Conditionally Passes TR C ••;m Needs Further Evaluation by the Local Approving Authority _ M :—+ X Fails { 0 Lco Inspector's Signature: - -- Date: 1/13/05 '�i,,���F R?1F1��.�0?�`° I NSPE``���� 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 applicable, DEP.The original should be sent to the system owner and copies sent to the buyer, if and the approving g authority. Notes and Comments: Liquid level in leaching pit at top of structure. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,11 Staysail Circle,Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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: Title P—m r,i,7nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 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: T410 G Tno—ti— 17--An Vlnnn 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Staysail Circle, Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 Criteria applicable to all s D. System Failure C pp stems:Y Y 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 '/2 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 forma _Yes_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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 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. T41a G Tnanvrtinn Fnrm 411 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 Staysail Circle,Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 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 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? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the conditio —n of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. _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)] Titles S Tncnantinn Fnrm�iTcnnnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Staysail Circle, Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 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:3 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)): 2003—92,000 gal.2004—103,000 gal.=267 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: Tank pumped three months prior to inspection Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM —X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _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: 1991 Were sewage odors detected when arriving at the site(yes or no): No Tula C lncnar}inn Fnrm 4/1 c1')nnn 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: 11 Staysail Circle,Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 6" 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: 8.5' long x 5.2' wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 13" 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.): Liquid level at bottom of outlet pipe,tees intact and clear. 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.): r.t TrtIP C 1"a f;n Vn 411 cnnnn 7 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: 11 Staysail Circle,Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 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: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Box set level,liquid level at bottom of single outlet pipe with no high stains. Extra knockout on box beginning to decay and leak. 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.): 8 T,+1.S Thar—+;— 17-411 ai,)nnn Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner: Michelle-Wright Date of Inspection: January 13,2005 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.): Liquid level in pit at top of structure above effective leaching capacity. 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.): Titls G incna f;nn Pn 411 cl')nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 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. Staysail Circle #11 29 15 20 31 27 40 Titlo G i--tinn.Rnrm 411 smnno 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner: Michelle Wright Date of Inspection: January 13,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 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: 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 repair to determine groundwater elevation. Titla C Incnartinn Rnrm 4/1 v'7000 1 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO7n1r, E-IVE�WT 7 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I (� Property Address: 11 Staysail Circle Marstons Mills MA 02648 MAP Owner's Name: Diane DeBarros Owner's Address: same PARCEL . -- LOT - Date of Inspection: September 26,2002 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 199 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)4284779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ° Date: %I&Q16 Z The system inspector shall submit a copy of this inspection report to the Approving Authority Y(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Staysail Circle,Marston Mills Owner: Diane DeBarros Date of Inspection: September 26,2002 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 ofthe 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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner.Diane DeBarros Date of Inspection: September 26,2002 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(l)(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 i 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 wells*. Method used to determine distance "*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner:Diane DeBarros Date of Inspection: September 26,2002 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 dogged 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%2 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 I of a public well. X Arty portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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 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—1WPA)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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 staysail Circle,Marston Mills Owner: Diane DeBarros Date of Inspection: September 26,2002 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)] Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Staysail Circle,Marstons Mills Owner:Diane DeBarros Date of Inspection: September 26,2002 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:_2 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)): 205 Sump pump(yes or no): NO Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment.- Design flow(based on 310 CMR 15203): gpd Basis of design flow(seats/persons1sgft,etc.): Grease trap print(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: Homeowner:Pumped summer of 2001. Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped:_____gAons--How was quantity pumped determined? Reason for pumping: Maintenance 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)No _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: House and system built in 1991 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Staysail Circle,Marstous Mills Owner: Diane DeBarros Date of Inspection: September 26,2002 BUILDING SEWER X_(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: 26' Comments(on condition of joints,venting,evidence of leakage,etc.): No leaks or signs of backup. SEPTIC TANK; X (locate on site plan) Depth below grade: 6" Material of construction:—X— — — concrete metal fiberglass—polyethylene other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000 Gal. 4.5'a 3' Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: i %" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 11" 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.): GREASE TRAP:—(locate on site plan) Depth below grade:— MaterW 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 fee 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 l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11Staysail Cycle,Marstons Mills Owner:Diane DeBarros Date of Inspection: September 26,2002 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: ltons Design Flow:_ %Wlons/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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet.invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box set level,No high water stains or solids. 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.)-. Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner:Diane DeBarros Date of Inspection: September 26,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): No damp soil or excessive 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 groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: t. 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: 11 Staysail Circle ,Marstons Malls Owner:Diane DeBarros Date of Inspection: September 26,2002 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. S-t�.�sa,l C1Q. 2'1 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Staysail Circle,Marstons Mills Owner:Diane DeBarros Date of Inspection: September 26,2002 SITE EXAM Slope Alone Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 25 Feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet.of SAS) Checked with local Board offfealth-explain: Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain:Checked USGS topo maps and town groundwater contours. You must describe how you established the high ground water elevation: Town groundwater contour map shows groundwater at EL.15. Property above EL.40. TOWN OF BARNSTABL E ✓ ,OCATION / ei�/�C� / L�'r SEWAGE # A d S ASSESSOR'S &L,OT NSTALI.EleS NAIVLE&PHONE NO. .;EP'I'IC TAl K CAPACrrY ACIiTNG EACIILITY: {type) ��•`n s-s (size) `�+ 5 .E 40.OF'BEDROOMS MILDER OR OWNER 'ERMIT®ATk?;..,...__..,.--,,....—,,—.L.,-,:QNt. LIANCE DA.TE:.�..._._ �I iaparation Distance Between the'. i vlaximam Adjusted,Groundwater Table to the Bottom of beaching Facility e et "rivate Water Supply Woo and Uacbing Facility (If mly walls exist on site or within 200 feet,of leaching facility) edge of Wedantl and Leaching Facility(if any wetlands exist within 300 feet pf caching facility) ` 4 sex 0 Pe . ga c e o t A - sy' F- 3o '> TOWN IGpCAMt]N: I � y 5a I �- r___ si~WAGE# VILLA p� G✓S 5ESa0R'S MA1'&LOT`zs�.. lN9T L EW4 NAME 8k PHbl"TE N0. -- -�--�---�-- %i 1 is TA1141 CAPACITY LEA!CitrnrG 1AC»ri.Y- - �p) r �f .(size) OR OWNL, PEgtNd$TY3 TN CON�t�r. rc I A ;�... Saps�rarsou T�u,P�,turc�3atv�ce�a tfie r' , Ninxiat�uni A P�1v 8c; �JAt�r Su lily 14Ri:aaui i ca hic¢ 1?1ci ty arty viols mist n satG cs wi¢►in; gL1 feet of i�astii¢a fstcility�) Migr o Wetland and Uac6 Ity,fif miy wMand5 cus¢ g+iiB.lai«:'A 0 ie6t Rd uiyins fsarility urnt3h�tl by s �-� �•.,.. [ eraL-i Q C O �rs er b F 27 6 9 s s , TOWN OF BARNSTABLE LOCATION 'OV ` `V LP/'/L/ ��'• SEWAGE# VILLAGE ./per• ASSESSOR'S MAP&PARCELS d� INSTALLERS NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO,OF BEDROOMS OWNER PERMIT DATE: �6 COMPLIANCE DATE: 86 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) 1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �'� �L / 19 % Fee J b s" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: K PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rptiration for Migpo5a[ *p5tem Con5tructiun Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I✓ ✓ !1 W e Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �.>>a' �dr'��'1-'-'j�" 11�,3"®,?�'? ��f''�'.�G�d✓ /�G&�'e�'/e.!; dP',P', .��o�-•g'9aIZ' Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building 6�' f'� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .S.�Q gpd Design flow provided 3 � gpd Plan Date Number of sheets ✓ Revision Date Title Size of Septic Tank a�' ��'rf / ` ��`� Type of S.A.S. v- Description of Soil Nature of Repairs or Alterations(Answer when applicable) t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo of Health. Sig Dated !,.Application Approved by Date (p r Application Disapproved`by: Date for'the following reasons Permit No. '� '� Date Issued No. (��6 d 60 Fee • �" y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - 21pplication for Migo!gal *p!6tem Construction Vermcit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. ` ./ G1� m Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �'i rn ,,�.cs'��`'il �7,1+'.�'0 9 �-'f'iP.Qcti� lyl��t-�R'I'. .T,/�, .3�oz-•Z'9.1.d ' Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building /���✓'• No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.req ed) 33?o gpd Design flow provided' 3 � gpd Plan Date "` Number of sheets. Re1vision�Date_ Title R ✓`' t'" r C Size of Septic Tank, J'y��/GSAl,6vd�► Type of S.A.S. Description of Soil ' Nature of Repairs or Alterations.(Answer when applicable) Date last inspected: _ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo rd of Health. Sig Date Application Approved by Date lJ Application Disapproved by: Date for the following reasons Permit No. (:Do l0 "',;;2 Date Issued Y" -------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (� Upgraded (r ) Abandoned( )by 4V at // J%T�,k .h/4/Z 4C/4'• .00V.0&'�l has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 6 — W dated Installer �''� '�C�.�ll�'U/� Designer �lq'G�/PG /y��/ '�i /P'r #bedrooms Approved design flow y� �� gpd The issuance of this peninit sha I not be construed as a guarantee that the system il1'1u�i •tion 9 tl�e ig ed. Date L�7 � � Inspector ——————————————————————— ———————————————————— No. ��!v Fee /y 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS ;Di.5po.5al *p!6tem Con6truction ermit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (R,)� Abandon ( ) System located at �/ fT/�y t�'�J•C �'Q . 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 condign . Provided: Constructio must brre completed within three years of the date f this perm',t. Date J1� Approved by TOWN OF BARNSTABLE LOCATION SEWAGE# `ILLAGE do ASSESSOR'S MAP & LOT055 OWCUL /J INSTALLER'S NAME&PHONE NO._ ��'�C k jW• D (-o44 e idtw SEPTIC TANK CAPACITY / 0 LEACHING FACILITY: (type) 4ki e) NO. OF BEDROOMS FOR OWNER �l(� C� e I, (�✓!a �y PERMITDATE: �OI�`LIANCE DATE: Separation Distance Between the: ��`' Maximum Adjusted Groundwater Ta�e��e Bottom of Leaching Facility Feet Private Water Supply Well and Le�ti~ing Facility (1f any wells exist on site or within 2W feet of leaching facility) Feet. Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by TOW OF B 5 TABLE LOCATION SEWAGE VILLAGE o "A ZMASSESSOR'S ZAP& LOT 66%tA DOI EWWWMR'S NAME&PHONE NO., s,�T/�G G �f SEMC TANK CAPACITY )v U• Z / ,EACHING FACILITY: (type) ( zed l — IN CHU NO OF BEDROOMS � j�m1 BUILDER 06 WNER PERMTTDATE: teemPL-I4CE DATE: Separation Distance Between the: 1i?S!/tc'-hc!✓ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by • 1 � �Ck � - q -� `� �� .. . 7a ; o �' i Z�I LC S-FAI lJW'r t- TOWN OF BARNSTABLE L(iCATION SEWAGE.# VILI,,AGE . 5 Ao" S /�� S ASSESSOR'S MAP 6t LOT5- —2— INSTALLER'S NAME & PHONE NO. ,) ��n �. ����� LAX f 5 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 7�4 f (size) NO. OF BEDROOMS ) PRIVATE WELL OR PUBLIC WATER '//v BUILDER OR OWNER A46 ' l DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �.3 No. � Fss7... FrI T COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �.� �- V1 ----- --d.w n ..............OF............. 'r nS'T.4 ......................................... r�` w pplirFaffou for BIipnoal 19orkii Tomitrurtion jJymit X NOVA 3 I3ispb Application ' eby made for a Permit to Construct X) or Repair ( ) an Individual Sewage sal System at: - - /,ot z .i19Qrs �,�/s................................ ..................... ...... - ----- ----•---••----------•--....-----•-----...----- ----•-----•----------...--•--_..... ation-Addre s or Lot No. !! G_ -5------' ----�--•-•----------- -- --- -----•--- -- -- ^-- --•• - ----• -------•- c.... W er Address a .......... � .... -------------•------- ........_...... Installer Address Type of Building Size Lot_.l af_zG.Z..Sq. feet Dwelling'.';_No. of Bedrooms_________________... ................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ......................... W Design Flow....................... S-------gallons per person per day. Total daily flow................. 3._.P...........gallons. WSeptic Tank Liquid capacity/oQQ_gallons Length.Z.�6.'�. WidthK f:g Diameter................ Depth_.-s�_7_ x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No-----,l------------ Diameter�q_:..0_'`-.. Depth below inlet--- Total leaching area.../.f9..sq. ft. z Other Distribution box ( A) Dosing tank ( ) W Percolation Test Results Performed by----------. .............................................................. Date......P,�!� 1 ..... ,a Test Pit No. 1...... _.....minutes per inch Depth of Test Pit-__eZ__......_ Depth to ground water..... G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground� water------------------------ i O - -+----42•--------•-- dip '' Description of Soil---------- 2•tom-,••-••r' '{.......!t4 ._........ .....-•••••-••••-......•-•-- .'� F ....................................... --..................... .sq . ---•--------------•-------_-------------------- V 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 iITLi� 5 of the State Sanitary Code—The undersign d further agrees not to place the system in operation until a Certificate of Compliance has been sued he boar / th. t ned------ - -----...•----•-- Application Approved �___.__._.••• r------- ------ ................. Application Disapproved for the following reasons-------------------------------------------------------------------- Date ------------ __.______ --------------------------------------------------------------- -----------•------•--•---------------------------------------------------- . ---- - ------------------------------___------ .. Date Permit No. � ----•---•...--••-----• Issued_......-/ ...................•------... Date Ir No................_....... FEB.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 3 ,Z, �/-e ...........r....`.`...' .................OF...................`............s......---------...... ...-----•--•-•-............... Appliration for Disposal Worko Toustrnrtion "rrmff Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: 4, 7-- z ..........`......U_-h........ ..........-................................... ......._........---------.........-•----------Lt . - ........ V o /O/ � eor C i'� -" e •---•--• ......-•-•................................................•-•----•----------------._.._........--- .... er Address ........... ....................................... .......----•-------•...............----•-••-•---•-•-•---.-•---••••-•-......•-••--•--•--------..... Installer Address Q Type of Building Size Lot... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — a YP g ---------------------------- P ( ) Cafeteria ( ) � Other fixtures ............................... .. ,. a r W Design Flow......................... _ _......gallons per person per day. Total daily flow.................. ©_........gallons. WSeptic Tank—Liquid capacitye Ge�',2.gallons Length.-!./�.'.. Width-y,-'c ,, Diameter-------------_ Depth.._.____�.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...../............ Diameter �..___5�...... Depth below inlet.......___...... Total leaching area...Z.r-�.sq. ft. Z Other Distribution box ( x) Dosing tank ( ) aPercolation Test Result Performed by.........L_ ------------------------------------------------------ Date...... !G -------- Test Pit No. 1................minutes per inch Depth of Test Pit....____.__......... Depth to ground water...... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O — / VZ Description of Soil ....................7---•-•---•-•-----------------------------------------------------------•---------------------------_•---_._-_-•---- U -• --•---------•--•-------••--------•---•------•-•-•-••-•-------•-••-•--•--••--_._... 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 TIT1�� 5 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 ofp1th. y—27. �p 1gned -----------•---.-•-- Application Approved---••-.��j , Date Application Disapproved for the following reasons:----•-------•-••-----------•------•------••---•-•---------------••-•-----•-•---•-----•----------•------••....... ................................................. --...................---------•-------•----.......-•------•••--••----•---.--------- Date PermitNo. •--•-CCCJ.... ...................... Issued.................... ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O-F�) HEALTH ........... !V..........0F......... J Q� ................ C9rrtifirair of Tompliattrr THI IFN Tja the Individual Sewage Disposal System constructed (�) or Repairedby......_... •---.��..... . i ..................................... J -----... ......_.........----•---------... --•--..._......----•-. at � \ V(,�, ` .yam t� V \ 1" t --------•---•-•-•-•-----•---•-•-----•................ '`� ..................... has been installed in accordance with the provisions of TI'TU 5 of The State Sanitary Code/as de ribs in the application for Disposal Works Construction Permit No..... �?..�__...�.-'9.. dated_.....1�(/...�.. �_.__`--'-1............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................................•••••-••-------•••----_-•-_.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD _OF HEALTH n r......... �� c. C( l ti?1)................OF.......... 1/\Y� ��1 (� ... l ^O,Z No................. .... FEE .. ......... Disposal Workii T n�tr wn rrmit �� � l Permission is hereby granted... •---.._.._.. ... ---•---•----------------•----.....-----••....:;_.-•---•--•-•-------....... to Construct ( ) or Repair ( ) an IndividuaL-Sew ge -- ..-•----..._.. is osl st at No.......�Q=�---••---�............. ......... -....... ....-•-•--••--- ............... .... --._ ............ Street �---�•�-•------- -•---•-- •---...........-- Street as shown on the application for Disposal Works Construction Permit No �43"'o �0 GDated------f_/_.__ �............ --•--••-•---•-•-•----•••••--------- •-------•------•--•-•-••-•---------•-------•--/lI3oard of Health DATE-------------------------------- ••----•-•--• FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS t 4 TOWN OF BA 'STABLE n } LOCATION Zo% <«:. S�i� 1�'." SEWAGE::# VILLAGE >' / ��/f ASSESSOR'S 'MAP & LOTS INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY ? ;LEACHING PACII.ITY NO. OF BEDROOMS j n PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED r �3 f t . DATE COLIPLIANCE ISSUED: - 1 VARIANCE GRANTED Yes No 4 T .._.. 1 i d7 , it ASSESSORS MAP : 5g TEST HOLE. LOGS NOTES: t PARCEL: 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR- J.V {V1G✓ { -�7 C�I� THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF �' a 3�00 1� L•E BOARD OF HEALTH REGULATIONS. Ro O FLOOD ZONE: NO�I (�{�Z t��it� WITNESS : '�.�-- (�J ]t� bp00 28 Cj9f Ao9 REFERENCE: pjY(� 15ul DATE: Upf 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, os CaRt o r.�-� p � PERCOLATION RA E::_`- 2- nn►ry I✓tG¢{ SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO RY "`CIR C l r' q Gt'A-S5, --r S6I S C'T-)94-=0'7�VPd��—�.Y INSTALLATION. a �UK/v tt TH_ I EL: (0; Cl j TH_2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION � [,� 0F A'�U_ __6 _ �•- �l�OS�iGV� !N� � SANS DETERMIN� - AND IONHALL NOT BE USED FOR PROPERTY LINE S�►�� �� - 4) ALL PIPING TO BE 4" SCHEDULE 40 @ I/S "J FOOT. (UNLESS LOCAT I ON MAP P-T-S. ,, . `ow'% SPECIFIED QTHERWISE) 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE DISPOSAL. N11�.Ojvm �P SJk-t�� 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) C (` MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. l.-A-t e PIT ID P,;E pump6.� (4vS4lep J w 07i�i,Ur ��-No Mowt1 rRa VA TE. W .-V7 w f 0) 1,r, of Rap. CPa c�r� SEPT I C: SYSTEM DESIGN G; 1�0 rVET BENCH MARK FLOW ESTIMATE .`� - GAS ftQ-ttsT� f3t,- E �D. or- F�A'LTlj �S TOP 0. GATE 2J BEDROOMS AT I(U GAL/DAY/BEDROOM - CAL/DAY _ELEVi\ i;u+4 i USGS DATUM ASSUMED `-- SEPTIC TA;;K r �j�j� G,iL/DAY x 2 DAYS - 0 GAL 66 S TA YSA IL / O� f 66 USE ( GALLON SEPTIC TANK- EWSTI NG� - ,JI°L�[E w/ !i 500 irQ:!ov) 92. / CIR CL IF I'�j t 6)9, o�A- cv 04 11 66 GAS14�1 SOIL A?St)RPTION SYSTEM UN>7�y�S[2E� ,l — 64 AT G E F p, _ o \�G w �1� off SlCES 4'S7�i�.� oivnS (ZS L x IZ��JX Z1D) �� :>;DE AREA: 25� +�lz��-fix 2 xS- Ex15TtN �P� 5�� �� BOTTOM AFEA: Z, x ( 2 x D���! 2 ZZ �o�' 6a1� GF I • --o 64 allN Q �< 4�N r 33o (�PU r� o/L� �o �m _ - SEPT I C �')YSTEM SECT I ON o 66 • Al z 70 13�{ c vies Ta O l t / r ty �� (p GT `IY J.s � Ya�1� 3G''�+tkX o/� / x Io. IhS�,I( I� EL- 65.C) o vvW ski e- �5 Ba�f(e>► �0(0.1�{ Ni O GAL �pS.7y �(Na�ar fcSt 3o D BOX / 6 9. L_l. = n = = �2. 3b SEPT I C TANK l Fa y 1,vge14esS S u r - E /S n�✓ - -! tk(e + z Da WOLSh e4 t he s.33i Z51 x 1 z 1w ---I - O T 2 Z;' ' - /l/ARE _ 1026 +- F0 •yI oN 7ESTH"d&C- "OFAfAS � S I TE AND SEWAGE PLAN 3 5� 70 N ," 7 E LOCATION : j /771- 561(. 6I1LO-GLa; . 1140 07,646 SgNITARN PREPARED FOR : N DARREN M. MEYER, R.S. SCALE:P:- l P.O. BOX 981 DATE: d J EAST SANDWICH, MA 02537 W DATE HEALTH AGENT Ph: (508) 362-2922 Z I -:. i -_ - _. , 1 _ ` F ,, • i. •. r .1.-.�C...,,1..1.II1%I.I.I..I.....II�;,d.-".I..I,.�..d..,dI_.:....1_d,.I..-I..,.�...-,I!I.I.,:..I..II,....::%,.,..,1;,I1"�.."I',,.��1..-I 1�..'..,1I..:......I;.:.�,I 1.1.I.�I..�I',"�.�.�.1..':,-...-..I.,1��;:..--...,.,II...I...';...I",.......*1.I.i.I..A-1.;.'�!'..:...."II,.I..I 1,I..,-�..I...rI ri;d:Ii.I I.N_!...e.,.1I I...'..1....d:.-'.rI.,..�....I.I1!..,..'I..I1._..'".,.-...I.I..III.4.I-.,......I".1,'.I.I.I*...1.1-I.I!-I.:...,....,.,.I.-.-..,.I.II".I I.I 1 I.,:,....,..I...II'...*m I..d....1.1.f.I,I I-P,....,*...-1,...........'..I..,�.I....I 1'....I_....I,.I..LP:.;I......I,..,+,,I...'I.1..;I1-I,.,....r....�.d,...d...1..I.I....I.:..I.......'...I�....,...Il......i:....-I....IP 1..`.,....1....�.....I...I.:..I...-....I�I I..I...."�..I.....-..1.......I....d..I....I--...I I.".:..I....I-.I.-I,....._......I,I-.-..�I*....t..1;.........I..I.-.I......:.I.-.,,........-I--.!-I--2---.r.-.-.....IIT.1.T..1�.;....�..1.4..,t I..I.. . . . _ E AIL• Rf 4';,IC II-I_d.--..-...._T�...l I........I-....P.I-.I I..I-.....+-._*.I_-----.5...I 4.-..0..-I-.I.A..,..I..-....I.I...I I�.......,I....0I.-1.........,....o.1.0.4.-IV.....:...,I t.>14 T.I.-.L;�.._..W.4....I,I_-7...I_y.....4I..._..';.........I I..1..._I.-_I......_...-.I..._1I-d__.'_...,_.-I_.1..,...I_._I.I..I II-,I..d,I ---.-.I-I---...-T.I-.'.I...�....'I.I—..-P4-I�I.".-.,..._..t I.:I.-I_.-...--4.�....I;1e ..-I._I1..I....!-.,I!..._....,.A..I-.,.-..I.._.,,..,.--..-.N I..._...�T..I_Lo.......I...0.:_!I Y.':..-�..I.-,r_r._......'..1-..:,...,..I.....I II l.........1?.-I......l.1 I_..I.I_....*....-II I.....,.,I...._. ...11.. .I.I..1.1.I.�1,......;...I......I..,d�......I..I.I....:.: �. - f TRIBU rON SOX DETAIL. ..I....I I..I.........I...................;I.I.I...-.................d....I..;I I,I I..�I..L.I.'.T.I..1.......A....:.'_.I.I I M..I...4.I 19...I....�I......I.A.....M.....TI.......I..Id'II...�..l.S.,........'...(.....'..U._II.I.._...._.I..L.._... ....D I..........,..I._�......d...,. 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INOICAT£>S rNotcAT£8 SEPTIC TANK DETAIL. D o r, �a �, o } . . NOT To SALE • P£r+c. -y oeaaERVEo NO•T TO SCALE NOT TO SCALE -c4.,,'...1-..,./;.�",I..,Ie.-I4�,.J 1 " N . . ;��/pr,1l-�.-,.1.1.'k.,.0.r.,. ,).0,.*,.'. I_? ".1-.. .I"-�!Ir i;i� JIfi II Ii I;I I: TEST' : OROUNOW�ITER NO. OF OUTLETS: �_ 21 " ! BROUGHT TOVFMi3H .GRADE LOAM 6 SEED ' T TANK ALL BE STEEL - ♦. INLET AND OUTLET TEES TO BE CAST rRON OR F-OR PA, - T I . . . NOTES:"1. SEP K S}l I -� REMIFORCEO CONCRETE. SCHEQ AO PVC. TEES TO BE CENTERED UNDER NOTES ---- �- ^' •- 0 51 rO 5D'a 2 SEPTIC .TANK TO WITHSTAND N•IO LOADING MANHOLE COVER r- -�- 1--- I. DIST. BOX TO WITHSTAND H-10 LOADING 2' MIN OF118' ! i GRO. EL. A2'5._ • GRD. EL., .- ^ GRD. EL•--_.� GRD- EL. . UNLESS UNDER PAVE WENT, DRIVES OR•' UNLESS UwOER PAVEwEKT, DRIVES OR TO I/.`.• ' 1 r2"MIN FILL Gw. EL. __ P_ GW. EL. _r� _�___ ' GW' EL• ..N1�►___ GW. EL.: _ D` TRAVELED WAY9,WHEREIN H-20 LOADING I I I TRAVELED WAYS'.WHEREMI H•20 LOADING WASHED _ ' oRECnST SONF •,'- O Q I h ` Ai I SMALL-APPLY. I �' SHALL APPLY. __ - 10=90w rlr f I DI$T I _ ��r . «. 70r4a1 _' I.5 0(5 . . 5 �'S 3 ALL PIPE CONNECTIONS AND CONCRETE r.•uNoLc cov[R 5 ) BOY I 1 2. PROVIDE INLET TEE OR BAFFLE WHERE SLOPE OF PVC- INLET PIPE p r c, o c� c3 a . � ILLY CONSTRUCTION TO DIE WATERTIGHT. �Ro�arrT ?o rrr.rs•• •A•o[ I 1 INLET PIPE EXCEEDS 0.06 FT./FT. OR IN �' r ,� _ ` ! .? I "j Y 14 8601 I. r, C)ILTY (.� 1 L. i I _ , PUMPED SYlTEM. ,r,-1 `�J .�,. 4� . NOTE o o c� u' c� o a �� GENERAL NOTES. ? L- - -,--• --J �:. (i.'• a G/L 1-l.P i� r e LEACHING PIT TO . hU a47f L_ . 2• t> �i' y J��' _ 3. . R3T TWO FEET .OF PIPE OUT OF DIET •- +' ' ' WITHSTAND N-i0 LOADING . I THIS ,PLAN IS FOR DESIGN AND ,1'MIR FI 1. .,:, '��.rj Ci11P�ib I V I� rl f covcA 80X TO EIE LAID LEVEL. a a o cD cn .c� a n n UNLESS UNDER . . .__ __•_ _ ..J .. •^ �' • i" CONSTRUCTION' OF THE SEWAGE I C.L�Y 4-1. �.--- - g -_- .�_ ___ ....�. ~� T PLAN VIEW . . `�' ! PRECAST 4e PAVEMENT,DRIVE OR ► .W 3/4"TO I•1/2" o o 1c-j r D = ,L.-I cam G n ' TRAVELED WAY WHEREIN DISPOSAL FACILITY ONLY. I L Rf I H-20 LOADING SHALL A 1l ... • MOlEABLE- L ,4 't7ll ,� I. �, .., �,,,-. N T- .0 ►. "AL WATER LEVEL _ - . Y --1 - -- - .OVEit � '1 A . DOUBLE LEACHING PIT ,,, 2- ALL CONSTRUCTION METHODS AND M5. r _ . _ - _ - _ _ _ _ _ _ _ ~ '1. • ''RID -_r.. ,, `. W f••� STO ED o a r I c� rm =7 rm m a rp APPEY. MATERIALS SHALL CONFORM TO MASS. yt _�_ f ��, ` _ ,� - D.E.O:E TITLE 5 ANO LOCAL BOARD ' 1 1 1� PRCYV,u • • • ' Lk I , FAO IoM-0 GG . I wL[T �c[ i _f. wATERTIG►+T OF HEALTH REGUL ATIONS .0 V • r , -- ... _ I 1 JOIN"S(r ) ,� I. •i �, W ;.o o o c� r� r_7 c� �7 c� O Ef' '" r ` �j,, m � • "' I.• •'-o Y'M.-' 4OUTLET " ♦ 1 l , r[[ I , �.i ��' . 9 3 ALL P..IPES LO_CATED•UNDER PAVEMENT ►11QCA�t(� :, fi►TK + i. f 1r0�►r0 o[►1NT[[ ♦' INLET ' �T[ j �.• ` �T�T .� , r 1 j , Y.o 0 o O r-] c t� .C7 C] II ' �, OR TRAVELED WAY SMALL BE (J 4, 1 .ji r oQ e - SCHEDULE 40 OR EQUAL. r• 1 1 ,• I. .. . • I z I�} 1 5 .;, N L- 1A 0 J __ __ ��• _ , t. - _ . - - - - - - - ... _ _ - -. --- I - - I L_' •L - - ► �_wTTbA ON _•_ , . . �� D1A. � ... • _ ,,..i , �p► N Alftt SOT TOY OM l[VEl 1TA�L[ (1•l[ .J.w., _ LEVEL STABIJE r , . . J _ o BILSE I I T f ION Y C kOS S SZ C , CROSS-SECTION VIEW _ . Pl,At+f VIEW _ "O55-SECTION 6 1" j,o �),'IT (-- . wD k ' � ;. 0C 0 .T1 V-- I . NO LJkfF,pf CONSTRUCTION NOTES 1L a 5 lf a :. 1� 311• o IZ �jp.v _ ) V ATt�.JNS. I"�� ;. . 3 f ^; OItTE: SATE: DATE: DATE: ' LC ( VATIOi vS: INVET ELEVATIONS. LOT iNVF�T ELEVAT1Of�S. �' INVERT EL ,, 1�,g I; . S A 14 a� 9 �� es INVERT EL.EVATIC�NS. r _ INVERT ESE �' �_ � t k'�. 55 5 INVERT AT BUILDING I---;- I . >� TEST BY: TEST BY:•'.. TEST BY. T ST BY: . - n Ar-' � '�•ei'''I� ------ tLDING +.-• INVERT AT BUILDING �'--• IttiVERT AT BU{LOING INVERT AT BUILDING _____,�_ 4�i-• G5 �IAA�. Pc _�N� Ass Eel . INVERT AT BU S, 4 ;Iq 1• 15 ` i7- I INVERT AT SEPTIC TANK(in) T 'A7 SEPTIC 7ANK(in) INVERT AT SEPTIC 7JlNK(in) INVERT AT SEPTIC TANK(in) .. � 4-0 ���►� D I� �/' WITNESSED 8Y: WITNESSED BY: WITNESSED BY: • WITNESSED Y: INVERT AT•SEPTIC TANK(in) Il INVER ,� '� ` ,440. Flo INVERT A7 SEPTIC TANK(out) f 1 (� .1� p,� �1t,J ►J(.- • E a n j ' 39.90 AT SEPTIC TANK(out) '� , If INVERT AT SEPTIC TANK(out) - INVERT'AT SEPTIC TANK(out) -Sr _r . J -_-_ .-170_ J-_ _.j_._L -j....__. _- .�Il.JL _ -^' INVERT AT SEPTIC TANK(out) - INVERT ___ r .ao � •80.'..' {NVERT AT DIST. BOX{in) C � H I &A I PER�ATE: PERC. RATE: PERC. RATE:' PERG. RATE: . �. , - ,�.� D RT AT. DIST. BOX(in) 4 �- � INVERT AT DIST. BOXGn) ` ' INVERT AT DIST. BOX(in) f_ • I MIN./M1C ____MIN./INCH __ �.�IMl:/INCH MIAI:/MlCH MVERT AT DIST. BOX(In) _ INVE . . - . 4-1> ( A4,.,,Ip �,6f INVERT AT DIST._BOX(out) . - 41 - �`0 INVERT AT DIST. BOX(out) --=- INVF-RT AT DIST. BOX(out) ' INVERT AT DIST. BOX(out) -- ' , ___._ ____ _ _-_ -__ -_,__ I .INVERT AT DIST. BOX(out) - c t- . 5a A LEACHING ' PIT ' '� ' 1NVER'F AT LEACHING' PIT INVERT AT LEACWING PIT _ ¢4 Od �i9�Jo INVERT AT LEACHING PIT IhVhRT T INVERT AT LEACHING PIT- . So . .. .. s�-3,0o •2 .01J BOTTOIv! OF LEACHING PIT O.OD F LEACHING PIT . . BOTTOM OE, LEACHING PIT I . DATUM. F 'ILEACHING P]T' • :. •' _ . �(c,0� • BOTTOM . OF LEACHING PIT 60TTdAR 0 . f . HOT'FDM 0 U .S.G -S.� MAXIMUM GROUND ' n . . ; UM GROUNI? U.S.G.S, MAXII�+tUl4I GROUND : _ U:S G.'S: MAXIi+AtaM GROUND• , �/� Y'� �✓ � . . . U . G.S:- MA GROUND G.S, MAXIM U.S WATER, ELEVATION . � , .. . C.�''� WATER ELEVATfON - VERTICAL DATUM: . WATER ELEVATION WATER ELEVAT3ON' ._.._.._. , ION, ' .__;____ ' . OBSERVE D . •GROUNDWATER ; . -WATER .ELEWAT A A4, or�� MII4ti . ". . . . , . . , . . . . . . . G UNDWATER -OBSER1rEIr? G# OUNDWATER „ ; " /'� L r . B ERVED GROUNDWATER OBSERVED RO . .. . . NDWATER O S C/ ) . ELEVATIO'N . . OBSERVED ' 4�i�R U `� BENCH MARK. : . ELE�/AT,IflN E USED �� VAT30N .- . I `6 -- E L E -.-..- �----- . ELEVATIO . N ., . '' '� . __.______ • AT{ N . . .. LE V 0 E I .. --. _ , , . . . • . . . . . r . ' . . . - . . . . .. .. .. -P • • - . . - - . �'. .. f -- , . .. '9, . N \Y . R T . E VA T V \/ t . . VE E�. T P T P T : - P 1 '`� 5 . P �.. . T - . , .. � _ Erg Q�1E3 a INVEST ' GRD. El.. .GRD. EL.:...�_ G , .Et, - �1• 15 ' I GW:-EL. . . Gw. El. QW. EL. - INVERT`AT-SEEPTIC- TANK(in) - .. . . . . --Gw E�.. " . • . J a14 � M� 5+t - f,� o c L- . . l.•90 ' . i I +- PTIC. TAN•K(out) . AT E I . ..Il�t VER S r, 5 . T140(L". til . INVEAT .AT DIST.'BOX60 . fir- =�°- . 1' ♦ INVERT A''r D=3T. BOX(out) ---- . . . Jg4 Ct V , . • • . I I. . �.. 0 c 5 ` l,�Y' s ' �, .�. AT LEACHING PIT -- I V E R T - -- - �1140 t. . . �5 ;�, ro -- - ___CI �� pL;;� rT� 1i. -.�,- � . �:_-� . . BOTTOM OF LEACHING PIT I ,� . 1 I T y :s hI 3 A . .,.. D • A .- - '� • Y - .. - w ' r , '.,x. .a ; ' 'tip , ,n Y DESfG►� L�r -. I�a^r?rr, 1-"""M ,,� v t t r r i sl',., y W�, R A ION ��..,ae r� ///� /-. ,,•� ,, � J .... , _,..-C��,iJi>>.;'�ir41, . e�.�•,il .S.I0 a.•.r__G�.i✓. ' 4, •., 11. r . .* _, _ 67 -• '3 ': j�h � y`'' OBSERVED GROUNDWATER y ' N 0 la&-P.A jtE G'f'jl��t � ,r a ,s,,,,. ,�v j« , r11 , L4 ,. l M(0 r Ix {/ _ h 1 _ ..1�" r . A Q ',!,, : --ll�j ELEVA'TiON g f_V w�--� k ,� S • r e a:I 1. .. . ➢I q 4 - - r 't e c. d I �'I7 _ The BSC GroupaH , REOUIRED SEPTIC TANK' . b� e `• �. `'. rrnu,r �. ?, "�� n .r ,`. , . N ';jj',rK�1+,,,y'ii"',!'�;,6�y �,'r' ''s, h°✓ r "e 1. "r, ?!I p , ,1..'. �' - - {0.. "p !Y. '�'�'' ay/,s.:cYl1+�ya. rl.. yy1 t 1 ':};+ ilS< .-+..yh)' t.S i �, 4 iI s t'1.r''�. § r , } � � .� .. �: �..�Fli'..si'�av_.,i-L'2 f�'ili,c�L.Cli.ra�.�"`t• 7*'., L� Y r .� .: I , - On I lO .y� I:' w. ,^y, ' ,F191 .09.n.j( ., -''. i' 6j',:IJ �.r n'¢Y;I�1. . k ,r::' • • Z1.15 , ' . SEPTfC9 TANK PROVIDED: = I� GAL. i 1 . hAN17 �( . . I . rev` rJh v 1 . . . , :• ' (l, ' • t4 .� - SIZE OF-;LEACHiNG':,FACLrTY REOUiREO: . %•5 r' he BSC Group-Cape Cod-tic . ATE. . '.�..-I..1 t....A.I.,*.....- .,...d&..,�.II�.m_. . DATEi OATEN+ DATE: s 't . ?�: •.. " ._., M�I�iNCH . IU Pf b Il,� B12 D DESKiH PERC.RATE: � :�-. ��Madaket Place ..I I..I-.4I...I.I......-...F..I...I-. T 9Y: TEST 8Y: TEST BY. - Route 28 TEST BY: TES - • .I . r If _ I . . . . . 33Q �'• a A I,e5 Y Mashpee MA - I BY: wsTt saFD •Y: . _ 02649 . WITNESSED BY: WITNESSED BY: WITNESSED __.._ ____ • ... , ,I . . l . . PERC. RATE: PERC. RATE: FIERC. !LATE. . 6�7 477 2525 . . PERC. RATE: '. . CH .____��_.MINI./MICR _._._MINJINCH •....____�_MMIJ�MGN . . MIN1Bi .. . • . , ' ' . SIZE OF LEACHdNG FACtLCi'Y PROVIDED: ` . . .. ' . . . • ' . . ; - I-to' I A. I{:(,Q DES. 1-r- 4T'oN _ of w,,�\ i I I VQ" oI� � t4 x r.(/ 1� �. �r I/. �J B. of r ,1 • . . I C Eh =I 10 x 2.5 s Z'15 la. a "lv CHI-MAN i . �, Z L f . . . . . . . ,/ / 1I - . . . _ • I . . j . r . NI ( HL.aAOZ� t . • . I I . . . III . .. ..._ . ..._ - . . . . ... ' . . . • ' . - . • DATE 1s�('T' 9 . Igoe I II ' , . . COMP'DESiGN IS . A. . 1-} . II III Ii . Ct�ECk _ _ f. . . . . . '- �... - ._ . I . . DRAWN ' 1, , 4 . , 41"7 "c . 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