HomeMy WebLinkAbout0076 TANBARK ROAD - Health 76 TANBARK ROAD
Marstons Mills `
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Commonwealth of Massachusetts �D -D -U191
Title 5 Official Inspection Form
!o� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` I
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address ib3
Karen Brady PO Box 880 -
Owner Owner's Name
information is
required for every South Dennis MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms P
on the computer, l7J
use only the tab Paul C. Martin
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services Inc.
use the return key. Company Name
350 Main St.
rab Company Address
West Yarmouth. MA 02673
City/Town State
Zip Code
508-775-2825 S15016
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
•2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6/10/2019
nspector's Signature -Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
<� 76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is South Dennis required for every MA 02660 6/3/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System in working condition.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally ,
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
C� Y 0 N ❑ ND (Explain below):
k
t6insp:doc r rev.7/26/2018 Tine 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�u 76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner information is Owners Name
required for every South Dennis MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
4,e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owners Name
information is
required for every South Dennis MA 02660 6/3/2019
page. City/-Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) -
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other.
LL
x
4) ,System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5irisp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
_ p Title 5 Official Inspection Form
i; S f b Susurace Sewage Disposal System Form-Not for Voluntary ry Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is
required for every South Dennis MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
/
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-,
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes • No
❑' ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone If of a public water supply well
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 1s
' r
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
X Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owners Name
information is South Dennis required for every MA 02660 6/3/2019
page. Cltyrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for of/inspections:
Yes No
- ® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up? ,
® ❑ Was the site inspected for signs of break out? a
® ❑ 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 CM 15.302(5)]
t5insp.doc rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is South Dennis
required for every MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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): 110x3=
Description:
330gpd
Number of current residents: Unknown
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® 'No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) El Yes',® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? El Yes ® No
Last date of occupancy: Current
Date
t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner owner's Name
information is South Dennis required for every MA 02660 6/3/2019
page. CitylTown
State Zip Code Date of Inspection
D. System Information (cont.)
t
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No•
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
3. Pumping Records:
Source of information: No Records
Was system pumped as part of the inspection? El Yes ® No
if yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5irisp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
n
Commonwealth'&Massachusetts
1. Title 5 Official Inspection Form
�8 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owners Name
information is South Dennis
required for every MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ 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:
1989 Per BOH Records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 36"feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line was checked with sewer camera and found to be clean, properly pitched with no sign of root
intrusion.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 1 e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owners Name
information is required for every South Dennis MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 26"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions:
1000Gal-
Sludge depth: 4-5"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 1-2"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers
26" below grade.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y<
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is required for every South Dennis MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: ` Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is South Dennis
required for every MA 02660 6/3/2019
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-10 DB-3 with 1line in and 1 line out in good conditon. Box is clean and level with minimal solids
carryover. No sign of overloading or hydraulic failure.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�o
�. 76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is required for every South Dennis MA 02660 6/3/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1-6x6
❑ leaching chambers number:
❑ leaching galleries number:
leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owners Name
information is South Dennis
required for every MA 02660 6/3/2019
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1-6x6 Pit with stone. 1'of effluent during inspection. No evident staining. No sign of overloading or
hydraulic failure.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
cry Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is required for every South Dennis MA 02660 6/3/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
�L, Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is South Dennis
required for every MA 02660 6/3/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owners Name
information is South Dennisrequired for every MA 02660 6/3/2019
page. Cltyltown State Zip Code Date of Inspection
D. System Information(cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +14'
feet
Please indicate all methods used to determine the high ground water elevation: u
❑ Obtained from system design plans on record
If checked, date of design plansreviewed: 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)
i
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand auger did not encounter water at 14'. Max bottom of pit is 10'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
,i Title 5 Official Inspection Form
!'} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
76 Tanbark Rd. Marstons Mills, MA 02648
Property Address
Karen Brady PO Box 880
Owner Owner's Name
information is South Dennis required for every MA 02660 6/3/2019
page. Cltyrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 18 of 18
Assessing As-Built Cards Page 1 of 2
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7(p ~ TOWN OF BARNSTABLE
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L 'CA�ION .�G1-II� T1��.,�7ti!k ,tl. SEWAGE#
VILLAGE 0/1,ttS t V%S kA.\1� ASSESSOR'S MAP& LOT a q-35-
INSTALLER'S NAME& PHONE NO. �c,J
SEPTIC TANK CAPACITY 1,666
LEACHING PACILITY:(type) LetiG LN, V[ (size) 1,1066 5 n f lOHS
NO.OF BEDROOMS lPRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER G `^ ���C `�eve�• CUi�
DATE PERMIT ISSUED: / -71 9
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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https://townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mapp... 5/31/2019
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7( TOWN OF BARNSTABLE
LOCEXTION—C-4 Ll 15 SEWAGE # Y�`T
VILLAGE Vyl^CS�V\s W` ,V�k( ASSESSOR'S MAP 6z LOT'T7`3�j
INSTALLER'S NAME & PHONE NO. _ �` G� I 777 �J i
SEPTIC TANK CAPACITY (4.66d)
°� (f�v►S
LEACHING FACILITY:(type) L e,,6(, Q4 (size) 1,06() 5 n l6kgS
NO. OF BEDROOMS Zj. PRIVATE WELL 1PUBLIC WATER
BUILDER OR OWNER -e ve L• coi�
DATE PERMIT ISSUED: 1 I -7 I
DATE COMPLIANCE ISSUED: ^ "
VARIANCE GRANTED: Yes No
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No--- 75.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
A n/srA/S ItL
------- .�0 t i,✓---- ----..O F.................................................
ApplirFation for Dispati al 01 Tonstrurtiva Vanfit
or Repair an Individual Sew a e Disposal
Application is hereby made for a Permit to Construct
System at:
iZ d/0; fy/JA-s roni$ ��L`s.......-
Locey ress Lot :�o.
......................^�iS2st� ( ti�; f�- d (E„v7t .lr
-• - ..... ............................. .--•.....-------•-
Owner Address
aIZIS('t7Z.i .�S' c,✓
Installer Address /� a
Q Type of Building Size Lot_______.,___________________Sq. feet
Dwelling—No. of Bedrooms._____`S__________________________________Expansion Attic (y ) Garbage Grinder (/✓)
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
a Other fixtures -•------•----------------------- -
Design Flow_______________r� ��______________________gallons per person per day. Total daily flow.._.._._----------------------------
Septic ____gallons.
W
Tank—Liquid capacity j_� __gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) /
Percolation Test Results Performed by_�Cv. ,.Ect)!� � t._ '___�`!_�� ___________________ Date__!/3�_! _________.______-.
1.4 Test Pit No. I-----e°-____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 Description of Soil s.vc--------.�-.'.eve.-----•-- -------- g ``3
x
U -•-----••--•------•-••-•-•--•-------••---•------------------------------------------•---.......-•---•-...•---•---------------------•-•--•------•-----••-•--•----------•••--•-------------•--•---------
w
UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
F Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of�i;'L
p 5 of the State Sanitar ode— he ersigned further agrees not to place the system in
operation until a Certificate of Compliance has a issue y t oard oVI ealth.
V��
---
Signed......-��•---•---------'�-�---------------------•--•---------- /� ...............
Date
ApplicationApproved By.............. -•• -.................... ----------------------------•• ------ -------
Date
' ------------------•-----•---•------------•------.._.-•-----------•----•---•-._ -•--•--------
Application Disapproved for the following reasons_______________
.........-•---•--------------•----------------------••-•----•----•--•---....-------------....-------••---...------------------•------••-•----•---•------------•-----•----•------••-•--•-•----••--•-------
q Date
Permit No.......... { s---
Issued.......................................................
Date
.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ----- -----------------------OF........-- . ••...........................
Appliration for Uispoiial VorTk Tomiuurtion "amit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
......... ..........................................................I..................... ..................................................................................................
LocPy,�;#lress 17 No.
. lx>, e), ;3("x �i/o Qt��tlr(14,v_ie,(k
.................................................... ................................../.............................................................
Owner Address
Installer Address
Type of Building Size Lot_____A...................Sq. feet
Dwelling—No. of Bedrooms.._...`:'.................................Expansion Attic (Y Garbage Grinder (Al)
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow______________- 5 _............gallons per person per day. Total daily flow--- �3 30 ................gallons.
............. ------------------------*9 Septic Tank—Liquid capacityLt,16'6---gallons Length________________ Width__....._._._._._ Diameter.___..._..._.._. Depth.____._..__.___.
Disposal Trench—No..................... Width............._._._.. Total Length_.................._ Total leaching area....................sq. f t.
Seepage Pit No--------------------- Diameter..........__.___.._. Depth below inlet.........._._._..... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank ( )
'_4 11 tM Percolation Test Results Performed byX.�u!i. ........:......j............................................. Date..... . `� .
.;i, "T A.,(
--- - ------
Test Pit No. I-----��111-----minutesperinch Depth of Test Pit----j-------- Depth to ground water_-_
Test Pit No. 2................minutes per inch Dept
of Test Pit_..______...__.._... Depth to ground water________..------__-____.
P4 ........... --------- ..... .......................................................................................................
0 C 1,f, (: �
�4 Description of Soil.1.....................................I---------7r..............................................................................................................
U ..........................................................................................................................................................................................................
-------------------------------------------------------------------------------------------------------------------------------------------- ...........................................................
U 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'TILE 5 of the State Sanitary-Code—The An'ersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued'Dy the board of health.
C11
Signed.....
-------*---------------------------------*--------------------------------*..... -----.......D"a't'e---
Application Approved By............. ... ................................... ...... ........
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo..........Q..... ..... ....;------------------------- Issued_.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF.....................................................................................
Tntifiratr of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
b j j- ;)0?J j !,r,( I r, --f 6^1
y------- ----- --------m------------------------------------------------------------------------------------------------------------------------------------------------------------------------
tip i,-) Installer
at..................................................................................1.......................................................................................................
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------- ------- dated.......... ..................................... .
_V........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector..................... ......��-------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ...................._OF ..........................................................................
No..0......:............. FEEW.L111
UWVosat .................
Permission hereby granted.. 1 -----� X -- �G-----------------�Sd-------....*...........*-------------------*------------- ......
-----------*------- --- -
to Construct (,,0 or Re an Individual Sewage Disposal System
atNo. ...............................................................j............. veo-v S-------------------------.......................................................
Srreet , —
*
as shown on the application for Disposal Works Constru ,Jb Permit No �11, Dated......./- -------7
V#41... ...
Board of Health �C_7_
...........................................
DATE...........
FORM 1255 H SEIB & WA
R.:N I INC.. PUBLISHERS
tARSTONS
SHEET 7A OF 7
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tamp ® ® = DESIGN CALCULATIONS:
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sox 66 NOTES:
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1000 GALLON SE1TIC TANK 1 +_I • I ! I s �roow�u TO I w OAZswL01 i Kwapio>tr m�
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SYSTEM PR t �► I • i wu•IW MMAMM�Pr To A X O•Yww TO e1MOt
SEPTIC a ALL aarwons or MI tANTARr titltl�!WL eT GN14t
ww w s•RL �� sOTln11 a LEST MOLE OF WOWMMM.0 1OA•w•IRRfa TMEr AN a OR
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e WAMM FOB 110w•0ax#AMAS ,FMN 1336-10 -
LOT
N0. ELEVATIONS LEGEND:
REV. 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 1FINAL VW Urallimi
47 148 149 a wrRwFsoE c
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C 70•1 6 s 13.7 ►e ►!`� $21 N 7L1 'Al 79.7 74.s t
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its 714 rt.• 7s, s4. 74.3 nipn.S�11•e i i►.s 4,1.0 Irf.b i4s 64•3 7k3 E
F 61•i N4 i•,1 ib► Yf t its H.6 7r.Y 71.t 7t.1 '7$•Y 7f.1 7f.Y 7FIr 76.6. 777 77.1 77.r 71 Y - 77.1 77 i '
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G i1.! ie f 65.0 ►►• if.0 L7:I ifs 71Fs 7Lo 7t.e �F o 73•f 7f.0 0..! 7&% mo 77.5 71-0 77.0 10,5 _ 77.a 77,0 � 1 1
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H 43.6 68•5 01.0 57.0 11.0 411.0 1►t•f ►4.f is.o 46.0 Ito 67.5 610 64•5 7••f 70-5 71.0 'R•o •,p 64•5 71.0 71.0
es.! (.7•f 64•0 ►e.o L4t Ys6 Y3s Y•s 17-.074.
is•f 64.0 7.0 ".o 4.i 64.5 Ys.0 Hf'46 li.f 44.0 640 H APPROVED: BOARD OF HEALTH
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M 72.0 71.0 670 "CO 1 io.0 641 Two 7t.0 7t.o Xs
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1 12 sa INITIAL ISSUE
NO. DATE DESCRIPTION BY
PERC TEST 1 PERC TEST 2 PERC TEST 3 PERC TEST 4 PERC TEST S SEPTIC SYSTEM DESIGN
LOT 116 LOT 125 LOT 131 LOT 146 LOT 146
MARSTONS MILLS WOODLANDS
-- - .ram w YA-fl,A -s. •da•a_.. . '
r N•Nal iw WV) r•tea w r•wNa w r now wr r•wNa w
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BARNSTABLE, MASSACHUSETTS
..+�,...� WOODLANDS ASSOCIATES REALTY TRUST
wMwNN FreAr M�wNeM•/•wRlw �� IT-H
NAIt �/` �_Ae Rt/w1 M mo tM •A••Ar< r,Ar•NRwn wrr,M N_Nww M SCALE: 1- 40 JOB N0. 1338�rswe `,.w y•�
•Aw1 W SCL 71lT`■=� •Al[a wi.=r2� SAW OF tot MT A" SATE a San=TJ1" DATt W tal 1DT�- w 0 Fo b
tTM •r wnsoem sr w11Otm•r AJ MMI
■11ltlD n AaL FgOo<AAgI RATE SLMwLA W PERCOLATION RATE SL0wLANa POawAT1g1 RAW SL.NLLAeH POIDOMOSY MAX-LMLAR71 Pvu=^N F RAZE SLrL/M
PERCOLATION SOIL TESTS IM =MGs TOM MOCAS INC.
aaml taiar�a� n�+ �a1m1e
Bee 1r»r 11Am1 a7 Clatrf l V= to 11Ysffi
�, p+► RD. SHEET 7 OF 7
aows � i
i
MARSTONS MILLS
LOT 130
• luw'! '
t101tR� .
AN LOT 129
� \ ort40.1 OFLOCATION MAP f 1 1 t
1e1 \
ROr� f �\ LOT 12t f
�( ad OT�32 $�7 h tuts s Y
�F �Ttae Sir 91e w
LOT 31
LOT 137 �� i vo
0 LOT 124_;:-
,mod LOT 106 '` 1 1 ,h,3, '+ y �` >L 1 y"Of d,0
r (' / ��l . r tn>rM �� . 9:. 1�1 � LOT 126 LOT 123`
-� . sa!
�^ �4► 14.b 1 t LOT 13 t4°7•!. yi 1i
+ 1• LOT 148
�� un•! ~ at LOT 130111,11114 IF 4-0
-1 -
+ Yf,•ar �. _ LOT 134 135 +! - - $
„1'••! L� s �s 1/ •� +''.�L07 121*AD
LOT 107 LOT 14e T!e / / I _ � daa 1 . !$ - •i*"' .. '
o - A.•o• °L;T 147mpg w ;` y , -A\ �,c -' L07119 $ �r : �� i Il 7►•
�f LOT 1141 1 � +� $ t••oo IF
lit 1 ► ' .4 '-� Y r o �11
p
�+ 1 1 I -�I q \\ t5,0 ) .;L01�142' '-' p ; SOT}aI
r.tr 1*1ly �. -1~L '��, roams - li \ 1Pa°°! dd : ' LOT 120 "
, LOT 117 .$ s1 t.-s
a•sr u 1 0 + T. -� 4tkA -�, kLOTA431` .�, + •+v� ",$ *A 1�I
i�i `.. �t '��-� - ,oalo•d ��'-'�'' $ pd ' `- 1.S !E QW-45 r 7A or
� '1 W1L Sc,t, yr s -ww1P
LOT 115 >P .+ -t'�QL Mw4 nsT. XC"wrs.
'• �' LOT 146 - L9�145 -` +t>r i Irma s ►$ o IL >e !.tlif f►tiGT 7A O1<7 'D2 �Ls6sND'.
Lot toe' ' ? n•a�ar' - nom! . Y r 14 ` �� t � 10 1
`ei ''o. 1 y l� ..
d
$�\ � " r' LOT 118
1r V ? ' LOT 113 M $ tomo s
11 I Ir
J- d• Y. LOT 111 i4amOT 1!
�I •I
Y 14.0• +1. - $ i_ !�+•
1 10.>f0�s` 17• ! •6 ,O.f a1 RpMD E. um4wnwb
$ 110 i1 Act
3 11 28 ee FINAL BLDG. AND A SEPTIC NLOCATIONS PAL
K _ �-L y PLAN DON
0 ! $ •>� 6 1 10 12 INITIAL 1 ELK
NO. DATE DESCMPTII BY
BUILDING LOCATION PLAN
+11 MARSTONS MILLS WOODLANDS
LOT 110 IM
LOT 109 °•M! BARNSTABLE, MASS CHUSETTS
WOODLANDS ASSOCIATES USTI
\ SCALE: 1" a 50' JOB NO. 1338/, '""�•
• so -
r..
LEVY, EDME & /ACNER ASS M INC.
see REST Hm STREET CMTERVMU MA 01:es2