Loading...
HomeMy WebLinkAbout0067 STONEY POND CIRCLE - Health 67 Stoney Pond Circle, Marstons Mills — _ A= 064 -068 -005 � A i Commonwealth of Massachusetts NIP D(Oy- D(Qg- OD5 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every J Marstons Mills MA 02648 5/1/15 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 1 �O on the computer, l use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service Company Name 17 Playground Lane Company Address �» Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S 14454 P _�' �U. 3s 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: x❑ Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/1/15 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 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: The septic system is in proper working order at the present time B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts 1p�WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with.approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The- system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. Cityfrown 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. ElThe 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 ❑ 0 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 ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than%day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IS Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 0 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. 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. El 0 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ z The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 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� 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? '❑ 0 Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) O ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? 0 ❑ 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: 0 ❑ 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 El 0 approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t%ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �•' 67 Stoney Pond Cir. Property Address er Tom Belekewicz information mation is Owner's Name required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes M No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes © No information in this report.) Laundry system inspected? 0 Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: NA 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•3113 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 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑, Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and.source of information: _ Were sewage odors detected when arriving at the site? ❑ Yes ❑X No Building Sewer(locate on site plan): Depth below grade: 1' feet Material of construction: ❑ cast iron H 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑x 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: 1500 gl Sludge depth: 311 t5ins•3113, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" 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 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap(locate on site plan): Depth below grade:. feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date.of last pumping: Date t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. Cityrrown State Zip Code Date of Inspection' D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•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 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1115 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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 is Ievel.Box has one outlet lateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 r - Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: 0 leaching pits number: 6'x6'with 3'stone ❑ leaching chambers number: 5 Infiltrators ❑ 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.): Sandy soil.No signs of hydraulic failure. 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 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. Citylrown 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 OR,IF a c 15W,3/13 Tffie S oft M h apsc"n Fam:st+baface Sew'ap rXs-W Sysh-•Pepe 15 wf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Site Exam: © Check Slope O Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 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) R Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USE D:Techn ical bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Stoney Pond Cir. Property Address Tom Belekewicz Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page_ Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked 0 Inspection Summary D (System Failure Criteria Applicable to All Systems) completed 0 System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Marstons Mills MA 02648 May 17, 2012 required for y every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information When J14forms on the computer,use 1. Inspector: only the tab key to move your Jason C. Ellis cursor-do not Name of Inspector use the return key. J.C. Ellis Design Co inc. Company Name P.O. Box 2152 Company Address Brewster MA 02631 City/Town State Zip Code 508-240-2220 IRS#1126 SI#3600 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 N OF A S ❑ Needs F I he Local Approving Authority HER LL N May 17, 2012 Inspector Sign re ASTER Date SgNfTARVP� The system inspe bmit 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. 1 t5ins•11/10 Title'5 Official InspectVFaSubsurface Sewage Disposal System-Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Marstons Mills MA 02648 May 17, 2012 required for Y every page. City(rown 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 satisfactory condition B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:subsurface Sewage Disposal System-Page 2 of 17, r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Marstons Mills MA 02648 May 17, 2012 required for Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety.or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Y required for Marstons Mills MA 02648 May 17, 2012 every page. . Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owners Name information is Marstons Mills MA 02648 May 17, 2012 required for Y 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: 0. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g 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 ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Marstons Mills MA 02648 May 17, 2012 required for y every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3(6) Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is y Marstons Mills MA 02648 May 17 required for , 2012 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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)): 2011-50 gpd 2010-41 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/lndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Marstons Mills MA 02648 May 17, 2012 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None 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 D.EP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal,System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M r` 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is y Marstons Mills MA 02648 May 17 2012 required for , every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Satisfactory condition Septic Tank(locate on site plan): Depth below grade: 2.5 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: 1500 gallons Sludge depth: 18" t5ins-11r10 Title 5 Official Inspection Fong:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is required for Marstons Mills MA 02648. May 17, 2012 every page. Cityrrown 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 16" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 2 How were dimensions determined? direct observation -measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank in satisfactory condition -inlet lid built up to 11" below grade-outlet lid 32" below grade Septic tank needs to be pumped. 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 k Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is y required for Marstons Mills MA 02648 May 17, 2012 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is y Marstons Mills MA 02648 May 17 required for , 2012 every 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.): D-box 44" below grade-satisfactory condition- lid was cracked and was replaced Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): s , If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '< 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Marstons Mills MA 02648 May 17 2012 required for Y every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): Leach pit in satisfactory condition - leach pit 65" below grade, lid built up to 17" below grade- 30"of liquid in bottom of pit 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•11110 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 "< 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Y Marstons Mills MA 02648 May 17 2012 required for , every page. Citylrown State Zip Code . Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is y required for Marstons Mills MA 02648 May 17, 2012 every page. CityTrown 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 DWFLc.tJtr . A FRoJT W O sir` O t-- TAat, O ,SCPTICL TAak_ 1...1 19.t' 17�3ox 33- 37 t l H P,T t5ins•11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is y required for Marstons Mills MA 02648 May 17 2012 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: 4'+ below pit 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: 6-20-1988 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: USGS Topo maps You must describe how you established the high ground water elevation: Elevation in leach pit location is 78'-groundwater contour elevation is 46' - USGS topographic and groundwater contour maps-4'+ (20') separation from bottom of pit and groundwater Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Stoney Pond Circle Property Address Gerald B. Sheffield Owner Owner's Name information is Marstons Mills MA 02648 May 17, 2012 required for Y every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page.15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ��- 005 j No. THE COMMONWEALTH OF MASSACHUSETTS Entered m computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftphration for Nspo8al Opstrm ConstCUttion permit Application for a Permit to Construct( ) Repair(") Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Cp --c"r�,�0 Q f�< 2 Owner's Name,Address,and Tel.No. Mcr s M CC-c. Very Assessor's Map/Parcel /Old 3 Installer's e,Address,and Tel.No. Designer's Name,Address,and Tel.No. gCo rr�r.vL .113 d\t) Y�rr.v�`M 2j Oar�t�. [ ►yGr R•b rSo+G 481 Type of Building: Dwelling No.of Bedrooms a Lot Size LOc2 0 sq.ft. Garbage Grinder()Vp Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 O gpd Design flow provided 3 a . gpd Plan Date a 17 Number of sheets '�, Revision Date Title Size of Septic Tank <-' Type of S.A.S. L S U U G c„ C\X, b-crJ Description of Soil C1 rr)\4,11 3 C,-j a S L X A[6LJ Nature of Repairs or Alterations(Answer when applicable) LZ C, C L. G- t"L S Date last inspected: —�—"-- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si d Date 6 Ia 7ZI 2 Application Approved by G,..a.✓Ly - ( Date Application Disapproved by Date for the following-reasons Permit No. ,20(� �-" Date Issued Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yet 2ppliration for Misposal 6pstem. Construction permit Application for a Permit to Construct( ) Repair(') Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 6 kCj,r,to C_r V, 2 d Owner's Name Address,and Tel.No. Assessor's Map/Parcel 1 CO f ' 6 cs Sit a n <"� S M G<< Vey�, Instaldekr-'s ark f d�rtess,,a`nd T IJNo.Ya r"M u ti' , 2 j Designer's Name,Address,and Tel.No' Type of Building: n Dwelling No.of Bedrooms Lot Size 0,) v sq.ft. Garbage Grinder(PP Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min..required) 3 3 o rgpd Design flow provided gpd Plan Date J a 17 Number of sheets �2 Revision Date Title Size 6 Septic Tank <X k Sk \0 0 o Type of S.A.S. .`-u d C Description ofSoil 5 c,-j a$ l k J J, _r L.7 X a Fe V �" N e w /o Nature of Repairs or Alterations(Answer when applicable) �P`Cl u wc k\ S N_% n G k W t t, E t"C C, Date last inspected: -Agreement: ~ The undersigned agrees to ensure�the':construction and,maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental-,Code and'not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S „ned Date �'A? Application Approved by Date .�q - Application Disapproved by Date - for tiie following reasons k Permit No. V+' Date Issued a' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(I/ Upgraded( ) Abandoned( )by �C o N ``� �r L,1.✓` at tas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '0�6 I -01O6 Z- dated Installer S N c \-rp n�� Designer #bedrooms Approved design flow lob gpd The issuance of this permit sh 11 not be construedas a guarantee that the system wi functi•n;as,4,desi,nDate ((� / Ins ectorr -- ---------------------------------- -------------------------------------- No. aG 17" 2 6rj l Fee ! THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS -Misposat *pstrm Construction Vermit Permission is hereby granted to Construct( ) Repair( � Upgrade( ) Abandon( ) System located at �0 7 C'N c,- V, R r^c rs}yl, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date b ! ` r Approved by i Town of Barnstalble Regulatory Services Richard V. Scali,Interim Director aniwsnesc.E. MASS Public Health Division �039. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: 17 Sewage Permit# - �Assessor's Map\Parcel 1.1 A Designer: Mein ,��5 I Y1 L Installer: .. . T Address: 0 B01 q� Address: �lc,_rt­A04—A1^ F�ioW 10 IVA U 6 01 On SC-0 was issued a permit to install a (date) (installer) septic system at jp ��(>✓}pr 1 ��based on a design drawn by (address) dated n (designer) ' FAe. x �y I certify thelseptil system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Strip out ff`required)was inspected and the soils were found satisfactory. I certify that the system referenced above was construct a with the terms of the RA approval letters(if applicable) DAM 572 ti I taller's Signa e N (Designer's Signature) (Affix Designer amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc I it Town of BArnstable. P# 1�35 Department of Regulatory Services Public Health Di on mateKAM& s l M�s 200 Main Street.Hyannis MA 02601 ; I IIate Scheduled �i< Time 1 Fee Pd. r z : oil SuitabMity .' s essmer�t for S ge Disposal Performed By: y �16r� witnessed Br i LOCATION&GENERAL INFORMATION Location Address'(07 T-k0 6 n n 1r . ) Owue s Name �G R . Mills j Address Assessor's Map/P4md: `W /?,t (� Q Enginr�s Name t` Ye/0'4 S lM S NEW CONSTRUtLON d� REPAIR ' Telephone# Land Use '\ S I J�`r t l� Slopes(�) , Surface Stones J _ Distances from: Open Water Body>— '200_11t Possible Wet Areal L—QLft Drinking Water Well �• aft I Drainage Way. ft Property Line ft Other tt • i SKETCH:(street name,dimcnsiods'of lot,exact locations of teat holes&pert tests,locate wetlands in proximity to holes) fey - 51 2-11)7 i _ I i . Parent material(geologic) IAJ I Depth to Bedrock Depth to taroundwatdr: Standing Water in Hole: �" i Weeping from I Face Estimated Seasonal Vgh Groundwater D ! TION FOR SEASO,"L HIGH WATER TABLE Method Used: . • 1. Depth 04erved standing" obs.hole: in. Depth to soil mottles: in. r Depth toiweeping from side of obs.hole I in. (1youndwater Adjustment 0. Index Well# Reding Date: Index Well level,.;.�....... �►dJ metot,,,,—�- Add.DttntiwatPt LeVtll.,,�s PERCOLATION TEST Date Thw Observation, E Time at 9" Bole# i �� 36 ,1 Depth of Perc Time at 6" ' Start Pre-soak Time.(� �0 1 Time(9"-G7 End Pre-soak Rate MinAnch Site Suitability Asse;;smeat Site Passed Site Failed; I Additional Testing Needed(YIN) i Original:.Public HeWlth Division Observatioli Hole DataiTo Be Completed on Back - ***If percola#gn test is to be conducted within 100' of wetland,,you must first notify the Barnstable C4.4servation Division at least one(1)wedk prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other . Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel 3 k(II'Dw. 2 7 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. �j Consistenc %Gravel) 6�ti��� tP fin. �'�/ �✓ DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. n isten ra Flood Insurance Rate May: Above 500 year flood boundary No_ Yes v_— Within 500 year boundary No Yes d}� Within 100 year flood boundary No Yes r l Depth of Naturally Occurring Pervious Material_ - Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring per 'ous material? Certification I certify that on f (date)I have passed the soil evaluator examination approved by the Department viron ental Protection and that the above analysis was performed by me consistent with the required tcainin xperti nd ez rience described in al.0 CUR 15.017. Signature Date Q:\SEPrICVERCFORM.DOC ti IA�Q �iE516N �ftTq / 1S Sir191c Farn►ly 3 acaroQmS ' �ac c/vsfr. zsLF�/i✓csic�» . DAILv �LOw (IC x. 3 = 330 :Gpc( 5�prlc MRNK 33o x zopy = GGO G;,llons Us4, ISO©'Gallon scpi-tc .-Tantc Dls�o®R.t_ ��r ti Uaa toCl� gat►cn•� ��•a` W114i 3.fcct c-f .. Gr•vshc-cQ. s•tonc j • SLo�wA�.L 22� 5'F Cr�ac�i-`�' Z26 x'Z,s = SGS•6 CAPAeITy I I X. I,o - 11 3 G eQ. Gg ��;a ' *q\,� TbTw�,>S 339 Sw 678 HEN min/trick " SAXTCri IST I LAIN • ?=Z=PAP Giv/c.- TE.Sr'�ae.E P•`ro�o�, Ly-3o:��� �•. �uNh�.� a.o.r(. a � Fes..3'�3•b .- ; �G �cS'3. o ;1,`I TG�F.Y.o,= 84•o0 �. ° ��•• � EaS ) /Soo c�L.� s /.Y✓, ez.zs �•� o,isr. „ l�h �; �c,w�t /s'Y BoX' /.v✓. ' GAL, /wti ;;�•, 36 80.0. tv, � B1vo 24,77' SEPrrG 81•oZ ' •• • +�;� ,, TANS. 143 folk .• it J. B1,47 . F • : �• G'.E.2T/F/Eo JPG OT f�,L%4,ti/�t. rb t= -7 51 oo LGTS .5jan� d�or�t/__Gic.�c: ,le 144' l/ekr 71.0 - / S;yow.v - •'/E.�E4.c/d ,G,/.�E . ti/�.f�'TI�AG.t: .2EQeF-til�Nr.S T: yIWW AelzJ /S .eEGisr�ec�.Garvo.S1i.21/Eya,�S it/GT GAS .2Y/LLc a. G DC.CT.F.O W/T/a�/y Ti�/�' L c1DpPL�Q//V. T.13.QfEp 4A/,Q,t/ Ta 5SrA94/Sy N s•�'avc.p.t 07 1- USEp 4 sb Q u fD � d 10 nn� ko c / poi l (� 06 t9 Ile , \ � hOTj � /. _ w Z 3 j A 58 S!(=/ � of / �= w pr 'Prop. o / 8ea oo,H L.Pp� A� Wo1er 1 l � Nouae V 1 F-Oti , Z \ %0 2//.3 1 �v �3 v �$Z ti ��q o4 ,aG R LE 51` I t�y ti• 2Eui5eo t FYI,F.�iF• 0/'1 �� IOTA\if /".��_ �'� !` ��� :' 44 1 L i t T�LF r 11t taty� ' o S7Z /Elm 'POND Ro.4� " °'" �ti4 `� �`^��s..�- ' ✓�i9�STONS ./r!/LL$ L�Zo 4 , xay.� e��� ��;�it;•�� !. SHEET 2 OF 3 Vim 7LIE a.` Vic,1&L c_ �Ea"L7 +•�lEx.s I hN I h I f OW-a 54.7�' Co•r.a-�o�5 .• 5p s qg Z3 q4.(o* •.. .. �'.1-- 0W2 �9 iOW4 I 49. OW3 FIGURE 6: GROUNDWATER CONTOURS i LEGEND OBSERVATION WELL 52 GROUND-WATER CONTOURS -+ DIRECTION OF GROUNDWATER FLOW SCALE: 1:1320 ic I?inC. sf/SET'' 3 of 3 gg Q .'_.:f_._ STo,s/�O IaQ C, TABLE WCATION L 4- # 5- p��� L vol SEWAGE # �� " l� _ f VILLAGE OMB{t��s �^'��S ASSESSOR'S MAP & LOT ®6 9L INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY I ►��� �����►s LEACHING FACILITY:(type) (size) 1�662,t Gl,�f NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER 6 d"L a 141 CO DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,� Al I � t � 1 I t s f TOWN OF BARNSTABLE LOCATION 67 S/'cr/,�YGi/IGL/6 SEWAGE # VELLAG li'/ ASSESSOR'S MAP &LOT�f �8 INSTALLER'S NAME&PHONE NO. I J G'J?i.See 77/- /o Yy SEPTIC TANK CAPACITY fS� �i9C LEACHING FACILITY: (type) (size) /22'� Cvf e- NO.OF BEDROOMS V BUILDER OAR �� A�.2urtri®,e<t 4i /�iS�`/rJ•� PERMITDATE: COMPLIANCE DATE: 11-111214/ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /y 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 /7(, �; `-� �'` FRvr? Dov/! �� S. w_ �� . , � , 1 O ry i � � , No...... ------ Fms- ct2 'T/ „ THE COMMONWEALTH OF MASSACHUSETTS ®� BOARD OF -HEALTH ......../--!?wi✓. -- -----....-.OF..... c� �rixs.>zr.�a%t.....- ------------- ----- Appliration .fur Uhip sal Workii Tow3 ur#ion Pumit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal Systemat......................... .......................................... ............................................... Lt .Locatio -Address orNo g ! - -•-------------- z6v.Y-- ------------------------------ ..-•-•••-•--•-•---(--t-- O�a z . ..Address ..------••-• -•-- t Y s AddressIn e U Type of Building Size. Lot.. 3 _9s0_r_Sq. feet Dwelling—No. of Bedrooms.__-..�xv!r------------------------Expansion Attic We) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures __________________________________ W Design Flow...................................... per person per day. Total daily flow..........a.31b.......................gallons. W Septic Tank—Liquid capacityl_4F�_gallons Lengtht4?`_ ."__ Width.' .'___ Diameter________________ Depth�_'.__`-'_-. x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area____A_.............sq. ft. Seepage Pit No----t�i2e.-_-_______ Diameter.....!_/...... Depth below inlet...6............. Total leaching area__IA!-------sq. ft. z Other Distribution box (N ) Dosing tank ( ) ~' Percolation Test Results Performed by........ c�x '_ t:____. n ____________________ Date___1:va:­9j____._________-. Test Pit No. I----a2........minutes per inch Depth of Test Pit.... Depth to ground ------ ......... fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to grountA oFMga, Description of Soil.... AL-Lv (� �L1ILSQJ�1_ errt W -------------------------_-- --._...-------•------------•-----------------•--•-•----•---------•--- --------•----•------------------•-------------•------- No.30216 O x V Nature of Repairs or Alterations—Answer when applicable______________________________•__________.._______________ ----------=---•------------•---------------------------------------------------------------------------------•---------•----------------------••••----------._. . S!�;d Agreement: e<<,e 2- _ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance wit the provisions of TT':"s-. y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... --- e Application Approved .....C17 �`K, ----------------------- ----•------ Datl' Date Application Disapproved for the following reasons:--•----__.-•-----------------------•----•----------•--....----------------------------------•--••--•---•••---••- ------•----------•-•----•..............•----•------------.••------•-•-•----------._.......-..•------•••••-----------•---------•--------------•---.----- ��� Date -- ----- Permit No. ---q--=--•------••------ •-"�--•••--- Issued --/ 1 •�to g - ---- ----------•--------------- No. ._. l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7a-.w,,l . ...............O F.....,��c'r rl.: . . Appliratinn for El ipngal Vnrkg Cnnntitrnr#inn rumit Application is hereby made for a Permit to Construct ( �) or Repair ( ) an Individual Sewage Disposal System at: --.......••---•••---•-•-•-••--------- ...- ...................................... .................. ............................................................... Location•Address 1 ! or Lot No. ............�.:eY.�eu7.uf..... Css� ..�itSL----•-----•-•-----•---•-----• •--••-._---------v+ --- wner Address G (C ---- -----------------------•----•.----••---------- •-••--•-••--•--- ...._ •-- l i ----•-------------------------___------- Installer Address Type of Building Size Lot_.a_�...VZ8.:..Sq. feet Dwelling—No. of Bedrooms.._._.TIAr ,&........................Expansion Attic W� Gar age Grinder ) Other—T e of Building No. of persons............................ Showers — Cafeteria p' Other fixtures .................................. W Design Flow....................................S5. __gallons per person per day. Total daily flow----------va o._____...............__gallons. WSeptic Tank—Liquid capacity,/.Sao..gallons Length ro.:.r.t.. Width d_.g►^___ Diameter-- Depths! 0.,_­ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___-a__.__--_•____sq. ft. Seepage Pit No._.o�-.---___- Diameter..... ,........ Depth below inlet..,.'.......... Total leaching area.3,3.?.......sq. ft. Z Other Distribution box ()(. ) Dosing tank ( ) � Percolation Test Results Performed by....� .- _. /y�____ n�-_•_-•_____________•- Date..ctra g. ................. Test Pit No. 1...,?---------minutes per inch Depth of Tesf Pit___f.¢+!� ..... Depth to ground wat - ___--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground �>;;(H® �i ---------------- an_ - Q a �, A STEPHEN y Description of Soil... -, __ _ fi} .�clbsa�� 3>� /�,+�q 5un�€vrrri •-- x • -• -------------------- --- ----------•------......._...-----•--•----•-••---•-••-•--•-••--••--•-----•-------•-----------•-.................................... Ho._3o21fiia U Nature of Repairs or Alterations—Answer when applicable._______________________________________________________•-•. ..--•-------••----•...................•---•------------••--•-•---••---------.....---------------------•---•-------------------•-----•-----•••------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T P1�•-• the provisions of :Tl:.'.�• 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 of health. Signed...................................................................................... ................................ Date Application Approved By.'.. :L4 �y.__._ _i'1'k .�^-_ Application Disapproved for the following reasons----------------•------•-----------------------------------.....-------------------------------••------•---._..._ / Date Permit No........a ..:... •----•---.-- J �----•--. Issued-----------•---- �;�_...--•-....._. Dj THE COMMONWEALTH OF MASSACHUSETTS �--- BOARD—OF HEALTH ........................... OF..............................................................I........ ........ T rfif iratr of TnntpliFatta ' THISil"S�T Gf IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ��_.11=... - •• _•-•----•- ----- ` �--v�--------- ................. �. �\S at.................... --•---••-••••--•---•-•........-•----.---------------------•- has been installed in accordance with the provisions of Tj L 5 of The State Sanitary Code �s described in the application for Disposal Works Construction Permit No-----------­-------­��-_5____ dated_....__`�?..- �__[ ��....._.._.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI1,L FUNCTION SATISFACTORY. DATE........... ......... �.... .............................. 1 � �....... --- InsPec --•---•-- � ---•---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ✓V N N .•.-•.................... FEE..........._.............. Uinpns�al, nrkii Tunitrnrtinn rrntit Permission is hereby granted................. ................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System � atNo..........�--:b+;------- - a; - = ' ra y-G ----.M.f.'tl._.�• _._...-----•-------------------•-••-•--•---- "-� Street as shown on the application for Dispos 'orks Construct' it No x d----------- ---/. . ............................................................ --•••........... ....................... Board of Health DATE-------------------------------------------- ' ' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS CERTIFIED SEPTIC SYSTEM _REPORT LOCATION 67 STONEY POND CIRCLE MARSTONS MILLS, MA � MAP 064 PARCEL 068.005 LOT 5 PREPARED FOR SELLER MR. ALEXANDER W . BISHOP 67 STONEY POND CIRCLE MARSTONS MILLS, MA 02648 BUYER MR. & MRS . GERALD SHEFFIELD 60 OXFORD RD. NEWTON CENTRE, MA 02159 PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Trudy Cox* WUm F.Weld s.u.un Ga"1101 David B.Struhs N9ft Psui Canutel commev�or»r U.Gomm SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: G 7 S%az1Z y G/.QG L/_-' Address of Owner. D of Inspection: a/a/y` (If different) Name of Inspector. �f/GG�fI1LU h'/LL�/1 Company Name,Address and Telephone Number. Ap Aoy P 5 p G S.tlriz e ell L L/, Ai,-7 3,t CERTIFICATION STATEMENT I�that I�personally inspected the sewage disposal system at this address and that the iiiformatioa reported.below is true,accurate inspection was performed based on. my training and experience in the proper function and and complete as of the time of inspection. The raa+nmance of oa dte sewage disposal systems. The system: _asses _ Conditionally Paases _ Needs Further Evaluation By the Local Approving Authority _ Fails . Iaspeator+s Sipatwre: - Date: 9��a3�JG The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of eomplsLing 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. rt apptop>riate regional office of the Department of Environmental Protection. r and copies seat to the buyer, if applicable and the approving authority. Tbs original should be sent to the system o-ne INSPECTION SUMMARY: Chas,C,or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15 303. Any fs&U%criteria not evaluated are indicated below. Bl. SYgTEK CONDITIONALLY.PASSES: Ons or mote system components need to be.replaced or repaired. The system upon completion of the replacement or repair.passes Indicate yes,m or not dacermined.(Y, N, or ND). Describe basis of determination in all instances. If-not,determiaed",explain why tot) The septic tank.is metal. cracked. arucnirally unsound. shows sub•taatal infiltration or exf:ltratios or tank failure is i.nnu ent. The system will pass inspec ion if the existing septic tank is replaced with a zouformiag septic tank as approved by the Board of Health. (revised 11103/95) 1 One VAntar Street • easton,.Masaachusetts 02108 • FAX(617) 556-1049 •- Telephone(617)292-5300 pmted an a.cwwe P%p" - r x• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Adduss: e- 7 Owner /*X'. Date of Inspection: �a/a Bj SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken.pipe(s) are replaced obstruction it removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety,and the environment. I) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE) DETMUKU4 S THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil.absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is$ee from pollution from that facility,and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. S) 017O R (revised 11/03"/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (oontinued) Property Address: G 7 Sror/�y /�ovo G//IGGl �i/�i�S TU,,�S /GGS Owner. 1h/l, AG�,r`/,LLyr/l L✓. /i/S/fc-/� Date of Impsationr DI SYSTEM FAIIA: < I hm determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis'for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged.SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or Cesspool. 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 V2 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 Soil Absorption System. cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I of a public well. Any portion,of a cesspool or privy is within 50 feet of a private water supply well. _ or privy is less than 100 feet but greater than 50 feet from a private water supply well with no Any portion of a cesspool acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for cobiorm bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The foDowing criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public bsalth and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinlang water supply _ the system is within 200 feet of a tributary to a surface drinlaag water supply _ the system is looted in a nitrogen sensitive area(Interim.Wellhead Protection Area(IWPA) or a mapped Zone II of a pte)lic wow supply well) Tha owner or operator of any such system shall bring the system and facility into full mmpiiance with the groundwater treatment,program regtsirmsats of 314 CUR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 v.A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: //IGG/= /97 Owner. iris. Date,of Inspection: •Check if the following have been done: _Pumping information was requested of the owner, occupant. and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _!.-:-As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. `The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. All system components,/�ecsuding the Soil Absorption System, have been located on the site. ✓The septic tank manholes were uncovered opened. and the interior of the septic tank was inspected for condition of.baffies or tees, material of construction, dimensions,depth of liquid depth of sludge,depth of scum. !/The size and location of the Soil Absorption System on the site has been determined based on existing information or appr%xximated by non-intrusive methods. -LZile facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. J (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Pt open,Address Owner. ig,e. Date of Inspection: FLOW CONDITIONS RFBIDENTIAI. Design flaw�llona Number of bsd:ooms:�_ Number of earteat residents: Garbage grinder(yes or no):�frLS Laundry opaaseted to system(yes or no): S Seasonal use"or no):—)--a // ) Water meter madinp, if available: Last date of occtpancy..-&",4 T4 COMMERCIAL/INDUSTRIAI- Type of establishment: Design fiow:--- __ allon Vday Grease trap present (yes or no)_. Iadwexisl Waste Bolding Tank present: (yes or no)_, Non4anitary waste discharged to the Title 5 system: (yes or,no)_ Water meter.teadiaga, if available: Last date of occupancy: OTHER:a)mcbe) Let data of occupancy: GENERAL INFORMATION PU PING RECORDS and source of information: / System Pumped as part of inspection: (yes or noi�� �C/1 C��vil/�iC /titer /T /JG�i+y�.�0 f�iC/y4�fjy If yes,volume pumped gallons Reason for pumping' TYPE OF SYSTEM �Lsgtk tankmitr on bou/scil absorption system Single cesspool Overflow cesspool Prig Rand system(Yea or no) (if yes,attach previous inspection reeards, if any Other(Mpwn) APPRO131A AGE of all components,date installed(if known) and source of information: ����9'/ SawaV odes denoted when arriving at the site: (yea or no I A--V (revised 11/03/") 6 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S' O�waer. Date of Inspection: SZFMC TANK:1� (locus on site plan) Depth below grada: Material of eavetion:Uoonayste metal_FRP—other(explain) Dimaoeiome:J5 do'fs"6aV) V'//;" O,C,60 ehidge depth; I- Distanos&am tap of sludge to bottom of outlet tee or baffle:�.6+. satin thicknaw: !/J- Distance bom tap of scum to top of outlet tee or,baffle: Dieu um from bottom of scum to bottom of outlet tee or baffle: Cammsnts: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leafage, etc.) 1gGvvQu A" "4gL GR ASF TRAP: (locus on Bite PL.;-)— Depth below pads: Material of construction:—concrete_metal _FRP _othenesplain, Dimensions: 8eom tbielmaas: Distance f4om top of scum to top of outlet tee or baffle: Distance f44om bottom of scum to bottom of outlet tee,or baffle: Commenw (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, avidence of leakage, etc.) (revised 11/03/95) g .. At; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C- SYSTEM INFORMATION (continued) Property Address: ce-'e Irv, sry vs .�iiLGs Owner., AIR 194-eX A&"It Date of Inspection: TIGHT OR HOLDING TANK'— /H (locate on site Plan) Depth bsbw Qade: other(explain) matarisi of won:_concrete metal— — Dimansians: Capacity sailoaa Dwign flow: _Mallons/day Alarm level;-- Comments: (condition of inlet tee,condition of alarm and float switches,etc:) DISTRIBUTION BOX. (locate an site Plan) Depth of liquid level above outlet invert— �— Cats' er, evidence of leakage into or out of box, etc.) %IE ✓��'��-�' (note if level and distribution is equal,evidence of solids=T7ov G SS L PUMP CHAMML 00cow on sits plan) p in working ordan(yes or no)— Comment- (now condition of,Pump chamber,condition of Pumps and aPPurtenaaors, etc.) (revi sod,11/03/95) 1 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) PropertyAddeesc Owner. Ale. AL,�X/1.��•E�t Gv ,�3/Sh`�yv Date of InspeoUo= SOIL ABSORPTION SYSTEM (SAs): t/ ODOM*an ate plan,if poenble;mcsvation not requited,but may be approrsmated by eon-intrusive methods) If not doWminsd to be present,e=plam: Type:. Lschias pits,number._L Lsehin;chambers,number:_ hsehiag sulieries,number: Lsehing trenches,number,length: Leching fields, number,dimensions: awrfiow cesspool,number: Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.) "if 4QG!/E� ✓li /� Th`�:�6 /%ld�l P .t� 6 G A iced �A CESSPOOLS- Ooeste on site plan) Number and camsgtrraticn: Depth-top of liquid to inlet invert Depth of milids*er- Depth of sow layer. Di=mdoas of oespook YatwisL of construction- Indication of gram"ater. blow(aampool must be pumped as part of inspection) Cammeatc(sots condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,.etc.) PRIVY:_ (loots on she plan) Materials of aonstxvetion: -Dimeasions: Depth of sands: Commmnc(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.) (rein sed.11/f73/95) S 77 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop"Mdn" f.7 s r-,f,r owner. Dated Inspection: SEBTCH OF SEWAGE DISPOSAL SYSTEM: iaeluda tine to at Last two permanent references Umdmarks or benchmarks locate an walls within 100, r-Row. . w a 0 _ IX DSPTH 7a GROUNDWATER Depth to aA.-A -tW-1L_f-t matbod d 4 to mination.ar appr=—tion: 9A/Iz-,-61A4Ai- 6/5 Sifvws Thy� moire AT SD' %N£ ra35�' UrJ� ld/dTi a Ti G,� vv� �iJa7 D/<'.44.yvG Sf/vu�5 rfi`E Gitcr�vo Gdi�Tadil 197- QGBrii°r �i'8 . THE t3v��.� a� Tf/e OiT /� /�pO/faxio� JYGY ,�/' D£L® TNL ri5G5 corYQ¢cTi�:� C SOt.✓ a53 ��� �� �S 7'- (revised it/03/99'), 9 .• Ir - - 4 LEGEND MARSTONS MILLS i PROPOSED CONTOUR PROPOSED SPOT GRADE FALMOUTH RD. EXISTING CONTOUR + 96.52 EXISTING SPOT GRADE W EXISTING WATER SERVICE GJ� c pG- TEST PIT OSS SCALE: 1"=20' o r �A- _ m� 1Q LOCUS .T� LOCUS MAP \ 73' LOCUS INFORMATION PLAN REF: 29500-D / TITLE REF: CTF# 152484 \� PARCEL ID: MAP 100 PAR. 031/002 00 - �T ,/ ZONING: "RF" FLOOD ZONE: "X" 73- wk COMMUNITY PANEL: 25001CO542J DATED:07/16/14 - ---- ---- G} y �� TP-2 4 \ SEPTIC SYSTEM 0 \19P REPAIR PLAN GAs \ \ o LOCATED AT: 67 TANBARK ROAD 72 ��,/ W1R O �� \\\ \ °" \ MARSTONS MILLS, MA. pVERNE AD ��` ' .v � �. PREPARED FOR \ '�\ h 0 N O l !� CT LOT 113 -' l�\ 1 20 ft >",> ' MARC VELA n . I AREA O = 102@Q,sf+— �f ,�O O iardD COURT PLAh ' I 295a0\D �� fps MAY 21, 2017 -7L �� ASSR 114AP1 OO Pci31—2 �. � -• 7- 71 \ 12J � \ A/ rn ��� OF 9S 72 o AR N M. , R , i SEC/SfE�� �3 WATER ,'PLO \ \ NITA0a� 17 GATE a \ 1 MEYER & SONS INC. O BENCH MARK P. O. BOX 981 PAINT S PLAN POT ON ® E. SANDWICH, MA 02537 BULKHEAD 9 CORNER PH. (508)360-3311 SCALE: 1 in = 20 ft bARNSTABLE GIS DATU fax (774)413-9468 0 20 40 meyerandsonstitle5®gmail.com O 10 20 40 SHEET 1 OF 2 J 1680 NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS T.O.F. NOTE: PLACE RISERS OVER ALL COVERS W/IN 6" OF GRADE FINISHED GRADE (72.2) EL: 73.55 F.G.EL: 72.8 F.G.EL: 72.5 F.G. EL: 72.30 n MAINTAIN 2% MIN SLOPE OVER LEACHING AREA .� 2" OF 3/8" DOUBLE WASHED TOP TANK=EL. 70.03 3/4" STONE OR FILTER FABRIC DOUBLE WASHED STONE A C" 4" SCH 40 PVC 10"1 14 6 �@j 1% MIN. ®®®®®®®®®®® TEE'S ARE TO BE INV.68.55 ( , ®®®®®®®®®®® .r 4' SCH 40 PVC 2 EFF. DEPTH1: ®®®®®®®®®®® INV.68.75 V.68 4' 2 X 8.5' 4' EXIST. INVERT GAS PROPOSED DB-3 Il _ BAFFLE EFFECTIVE LENGTH = 25, DISTRIBUTION BOX INV. 69.0 INV. ELEV.= 68.20 EXIST. 1 ,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON �YN, �F ss9� BREAKOUT OUTLET TEE AS MANUFACTURED BY yo TUF-TITE, ZABEL, OR EQUAL DARE IRM: TOP CONC. ELEV.= 69.20 ELEV.= 69.20 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING " 1 40 " INV. ELEV.= 68.20 R g ®®®PIPE INVERTS PRIOR TO CONSTRUCTION ®®®®®®2) D-BOX SHALL BE SET LEVEL AND TRUE TO fG/$Ttn`" ®®®®®® 'GRADE ON A MECHANICALLY COMPACTED SIX NIT00 BOTTOM EL.= 66.20 ®®®®®® ,INCH CRUSHED STONE BASE, AS SPECIFIED IN 21 35 FT. 3,75 310 CMR 15.TING 1 EFFECTIVE WIDTH = 12.5' 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK SEPARATION 5.00 FT. WITH 1500 GALLON SEPTIC TANK IF FAILED, SEPTIC SYSTEM PROFILE DAMAGED, OR UNDERSIZED. ! SOIL ABSORPTION SYSTEM SECTION 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 61 .20 � (SECTION) GAS BAFFLE AS REQUIRED (500 GALLON LEACH CHAMBER) GENERAL NOTES: SOIL, LOGS P#: 15357 DESIGN CRITERIA **NO PROPOSED INCREASE IN FLOW" I. ALL CHANGES To THIS PLAN MUST BE APPROVED BY THE LOCAL NUMBER OF BEDROOMS: 2 BEDROOM DWELLING/3 BEDROOM DESIGN BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: MAY 18, 2017 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPO/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE SOIL EVALUATOR: DARREN MEYER, CSE 1614 DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR WITNESS: DON DESMARAIS, BARNSTABLE HEALTH DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE I GARBAGE GRINDER: NO (not designed for garbage grinder) DESIGN ENGINEER. TP-2 Depth SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXIST. 1,000 GAL. SEPTIC TANK Elev. TP- 1 Depth 1 a� P , � 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 73.02 0" 1 72.70 0" ENGINEER BEFORE CONSTRUCTION CONTINUES. A LOAMY SAND l: A LOAMY SAND LEACHING AREA REQUIRED: (330) = -445.94 S.F. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 10YR 3/2 10YR 3/2 .74 ., 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 72.60 5" 72.28 5" THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 8 B 1 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4 LOAMY SAND LOAMY SAND tl 7. WATER SUPPLY PROVIDED BY MUNICIPAL WATER. 10YR 6/6 10YR 6/6 STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D 8•ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 70.10 35" 69.87 C 34" BOTTOM AREA: 25' x 12.5'= 312.50 SF TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. C 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE MEDIUM MEDIUM SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING BOTTOM SAND SAND CONSTRUCTION. PERC ® EL 68.52 TOTAL SQUARE FEET PROVIDED = 462.50 vs. 445.94 REQ'D 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2.SY 7/3 2.5Y 7/3 DESIGN FLOW PROVIDED: 0.74(462.50 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY PROPOSED SEPTIC SYSTEM UPGRADE PLAN AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 62.02 132" 61.20 138" 13. NO ABUTTING PRIVATE WELLS WITHIN 150' of PROPOSED LEACHING. 67 TANKBARK ROAD, MARSTONS MILLS, MA 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. PERC RATE <2 MIN/IN. (-C- HORIZON) NO GROUNDWATER OBSERVED Prepared for: Vega 15. ALL PIPING TO BE 4' SCH 40 ® 1/8'/FT.(UNLESS SPECIFIED) System Design and Topography Plan by: SCALE DRAWN • 1, Darren M. Meyer, MEYER&SONS,INC. N.T.S. DMM.R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX98f to conduct soil evaluations and that the above analysis has been performed by me consistent with the DATE CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certif y that I have passed the Soil Evaf. Exam in October, 1999. EAST SANDWICH,MA 02537 50"2-2rl 05/21/17 DMM 2 Of 2